View source for Varicocele

{{Short description|Abnormal enlargement of the pampiniform plexus veins in the genitals}}
{{Infobox medical condition (new)
| name            = Varicocele
| image           =
Photo légendé d'une Varicocèle.jpg
| caption         = Varicocele on the person's left testicle. Notice the swelling and slight enlargement of the left testicle, which is marked by an arrow.
| field           = [[Urology]]
| pronounce       = {{IPAc-en|ˈ|v|ær|ᵻ|k|oʊ|ˌ|s|iː|l|,_|-|k|ə|-}}{{refn|{{MerriamWebsterDictionary|access-date=2016-01-21|Varicocele}}}}{{refn|{{Cite encyclopedia |url=http://www.lexico.com/definition/Varicocele |archive-url=https://web.archive.org/web/20201204201257/https://www.lexico.com/definition/varicocele |archive-date=2020-12-04 |title=Varicocele |dictionary=[[Lexico]] UK English Dictionary |publisher=[[Oxford University Press]]}} }}
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<span lang="kn">A</span> '''varicocele''' is an abnormal enlargement of the [[pampiniform venous plexus]] in the [[scrotum]]; in a man, it is an abnormal painful swelling to the [[List of related male and female reproductive organs|embryologically identical]] pampiniform venous plexus; it is more commonly called [[pelvic compression syndrome]]. In the male varicocele, this plexus of [[vein]]s drains [[blood]] from the [[testicle]]s back to the heart. The [[blood vessel|vessel]]s originate in the abdomen and course down through the [[inguinal canal]] as part of the [[spermatic cord]] on their way to the [[testis]]. Varicoceles occur in around 15% to 20% of all men.<ref name="WhiteKimMobley2019">{{cite web |last1=White |first1=Wesley M. |last2=Kim |first2=Edward David |last3=Mobley |first3=Joe D |title=Varicocele: Epidemiology |url=https://emedicine.medscape.com/article/438591-overview#a7 |website=[[Medscape]] |access-date=18 September 2019 |language=en |date=2 January 2019 |quote=Although varicoceles appear in approximately 20% of the general male population, they are much more common in the subfertile population (40%).}}</ref><ref name=KupisDobronski2015/> The incidence of varicocele increase with age.{{citation needed|date=September 2024}}

==Signs and symptoms==
Varicocele might be noticed as soft lumps, usually above the testicle and mostly on the left side of the scrotum.<ref name=NHSlumps/> Right-sided and bilateral varicoceles also occur. Men with varicocele can feel symptoms of pain or heaviness in their scrotum.<ref name=NHSlumps>{{cite web|title=Testicular lumps and swellings - Causes - NHS Choices|url=http://www.nhs.uk/Conditions/Testicular-lumps-benign/Pages/Causes.aspx|publisher=NHS Choices|date=7 October 2014|access-date=20 June 2017|archive-date=24 August 2017|archive-url=https://web.archive.org/web/20170824143458/http://www.nhs.uk/Conditions/Testicular-lumps-benign/Pages/Causes.aspx}}</ref> Large varicoceles present as plexus of veins and may be described as a "bag of worms".<ref>{{cite journal |last1=Cannarella |first1=Rossella |last2=Calogero |first2=Aldo E. |last3=Condorelli |first3=Rosita A. |last4=Giacone |first4=Filippo |last5=Aversa |first5=Antonio |last6=La Vignera |first6=Sandro |title=Management and Treatment of Varicocele in Children and Adolescents: An Endocrinologic Perspective |journal=Journal of Clinical Medicine |date=8 September 2019 |volume=9 |issue=8 |page=1410 |doi=10.3390/jcm8091410 |pmid=31500355 |pmc=6780349 |doi-access=free }}</ref><ref>{{cite book |last1=Leslie |first1=Stephen W. |last2=Sajjad |first2=Hussain |last3=Siref |first3=Larry E. |title=Varicocele |date=7 October 2019 |publisher=StatPearls [Internet] |pmid=28846314 |url=https://www.ncbi.nlm.nih.gov/books/NBK448113/ |access-date=20 January 2020}}</ref> Varicocele is sometimes discovered when investigating the cause of [[male infertility]].<ref>{{cite web|title=Low sperm count|url=http://www.nhs.uk/conditions/low-sperm-count/Pages/Introduction.aspx|publisher=NHS Choices|date=2 August 2016|access-date=20 June 2017|archive-date=14 September 2017|archive-url=https://web.archive.org/web/20170914183459/http://www.nhs.uk/conditions/low-sperm-count/Pages/Introduction.aspx}}</ref><ref name=Baazeem2011/>

==Cause==
[[File:Gray1147.png|thumb|Diagram of spermatic veins]]

There are three main theories as to the anatomical cause; the first has to do with the geometry of the veins, wherein the vein on the left side connects to the larger outflowing vein at a right angle, which tends to fail; the second is that testicular valves that are supposed to prevent backflow fail (venous insufficiency) leading to swelling and compression of the valveless [[pampiniform plexus]]; the third is due to excessive pressure in upstream veins, created by [[nutcracker syndrome]].<ref name="Eisenberg">{{Cite journal|last1=Eisenberg|first1=Michael L.|last2=Lipshultz|first2=Larry I.|date=2011-01-01|title=Varicocele-induced infertility: Newer insights into its pathophysiology|journal= Indian Journal of Urology|volume=27|issue=1|pages=58–64|doi=10.4103/0970-1591.78428|issn=0970-1591|pmc=3114589|pmid=21716891 |doi-access=free }}</ref>

==Pathophysiology==
Often, the greatest concern concerning varicocele is its effect on male fertility. The relationship between varicocele and infertility is unclear. Some men with the condition are fertile, some have sperm that are normal in shape and move normally but are compromised in function, and some have sperm with abnormal shapes or that do not move well.<ref name=Eisenberg/> Theories as to how varicocele affects sperm function include damage via excess heat caused by the blood pooling and [[Reactive oxygen species|oxidative stress]] on sperm.<ref name=KupisDobronski2015>{{cite journal|last1=Kupis|first1=Ł|last2=Dobroński|first2=PA|last3=Radziszewski|first3=P|title=Varicocele as a source of male infertility - current treatment techniques.|journal=Central European Journal of Urology|date=2015|volume=68|issue=3|pages=365–70|doi=10.5173/ceju.2015.642|pmid=26568883|pmc=4643713}}</ref><ref name=Eisenberg/><ref>{{Cite journal|last1=Hayden|first1=Russell P.|last2=Tanrikut|first2=Cigdem|date=2016-05-01|title=Testosterone and Varicocele|journal=The Urologic Clinics of North America|volume=43|issue=2|pages=223–232|doi=10.1016/j.ucl.2016.01.009|issn=1558-318X|pmid=27132580}}</ref><ref>{{Cite journal|last1=Dabaja|first1=Ali|last2=Wosnitzer|first2=Matthew|last3=Goldstein|first3=Marc|date=2013-08-01|title=Varicocele and hypogonadism|journal=Current Urology Reports|volume=14|issue=4|pages=309–314|doi=10.1007/s11934-013-0339-4|issn=1534-6285|pmid=23754533|s2cid=5477034}}</ref>

[[Smoking|Tobacco smoking]] and mutations in the gene expressing [[glutathione S-transferase Mu 1]] both put men at risk for infertility; these factors may also exacerbate the risk that varicocele will affect fertility.<ref name=Eisenberg/>

==Diagnosis==
Following discovery of the sign of swelling comprising a mass, varicocele can be confirmed with [[scrotal ultrasound]], which will show dilation of the vessels of the pampiniform plexus to be greater than 2.3 mm.<ref>{{cite book |last=Salam |first=MA |date=2013 |title=Principles and Practice of Urology |url=https://books.google.com/books?id=efG8AQAAQBAJ |location=New Delhi |publisher=Jaypee Brothers Medical Publishers |page=752 |isbn=978-93-5025-260-4}}</ref>

<gallery mode="packed" heights="175px">
File:trans varicocele.tif|Varicocele in ultrasound (left: testicle)
File:Varicocele.png|Varicocele
</gallery>

=== Criteria ===
A universally accepted system for categorizing varicoceles does not exist, but according to the classification criteria established in 1970 by Dubin and Amelar, most commonly varicoceles are clinically assessed and categorized into three grades as follows:<ref>{{Cite journal |last1=Bertolotto |first1=Michele |last2=Cantisani |first2=Vito |last3=Drudi |first3=Francesco Maria |last4=Lotti |first4=Francesco |date=September 2021 |title=Varicocoele. Classification and pitfalls |journal=Andrology |volume=9 |issue=5 |pages=1322–1330 |doi=10.1111/andr.13053 |issn=2047-2919 |pmc=8596817 |pmid=34038625}}</ref><ref>{{Cite book |author=A. Hamada |display-authors=etal |date=2016 |title=Varicocele and Male Infertility |series=SpringerBriefs in Reproductive Biology |url=https://www.clevelandclinic.org/ReproductiveResearchCenter/docs/publications/157_Hamada_et_alVaricocele_Classification.pdf |doi=10.1007/978-3-319-24936-0 |isbn=978-3-319-24934-6 |s2cid=5203944 |archive-date=2023-10-04 |access-date=2023-10-04 |archive-url=https://web.archive.org/web/20231004205627/https://www.clevelandclinic.org/ReproductiveResearchCenter/docs/publications/157_Hamada_et_alVaricocele_Classification.pdf }}</ref>

# '''Grade 1 Varicocele''': Characterized by the [[Palpation|palpability]] of the varicocele only when the individual is in a standing position during the [[Valsalva maneuver]].
# '''Grade 2 Varicocele''': The varicocele is palpable not only during the Valsalva maneuver but also at rest while standing.
# '''Grade 3 Varicocele''': The most severe grade, where the varicocele is not only palpable but also visible through the scrotal skin, without any additional maneuvers.
In the Sarteschi (1993) classification system, varicoceles are categorized into five grades:<ref>{{Cite web |last=Namdev |first=Rupesh |title=Varicocele grading on color Doppler {{!}} Radiology Reference Article {{!}} Radiopaedia.org |url=https://radiopaedia.org/articles/varicocele-grading-on-colour-doppler-1 |access-date=2023-10-04 |website=Radiopaedia |language=en-US}}</ref>

# '''Grade I''': Reflux occurs solely at the groin level during the Valsalva maneuver, without evident scrotal deformation or testicular atrophy.
# '''Grade II''': Reflux is limited to the proximal segment of the pampiniform plexus during the Valsalva maneuver, without scrotal deformation or testicular atrophy.
# '''Grade III''': Reflux occurs in the distal vessels located at the lower scrotum exclusively during the Valsalva maneuver, and there is no scrotal deformation or testicular atrophy.
# '''Grade IV''': Spontaneous reverse blood flow is present and intensifies during the Valsalva maneuver, resulting in scrotal deformation and the potential for testicular atrophy.
# '''Grade V''': Resting reflux is evident within the dilated pampiniform plexus, possibly escalating during the Valsalva maneuver, and is consistently accompanied by testicular atrophy.

==Imaging==
Manual examination of the scrotum is required for proper interpretation of ultrasound images. During ultrasound examination, the diameters of the veins in the pampiniform plexus are measured, and regurgitation is measured. The subject is then instructed to stand up and [[Valsalva maneuver]] is performed. The diameter is then measured, and changes in blood flow direction are recorded to assess for regurgitation.<ref name="pmid28138407">{{cite journal |vauthors=Lorenc T, Krupniewski L, Palczewski P, Gołębiowski M |title=The value of ultrasonography in the diagnosis of varicocele |journal=Journal of Ultrasonography |volume=16 |issue=67 |pages=359–370 |date=December 2016 |pmid=28138407 |pmc=5269523 |doi=10.15557/JoU.2016.0036 |url=}}</ref>

==Treatment==
{{missing information|what each surgical option entails (what is done to the local tissue to solve the issue)|date=March 2025}}
[[File:Wound after microsurgical varicocelectomy.jpg|thumb|Wound after microsurgical varicocelectomy]]

The most common surgical approaches are [[retroperitoneal]] (abdominal using [[laparoscopic surgery]]), infrainguinal/subinguinal (below the groin), and [[Groin|inguinal]] (groin using [[percutaneous]] [[embolization]]).<ref name=KupisDobronski2015/>

Possible complications of this procedure include [[hematoma]] (bleeding into tissues), [[hydrocele]] (accumulation of fluid around the affected testicle), [[infection]], or injury to the scrotal tissue or structures. In addition, injury to the artery that supplies the testicle may occur, resulting in a loss of a testicle.<ref name=KupisDobronski2015/> 

Many people have reported post-operative pain after varicocele embolizations, which could be linked to metal sensitivities, nerve irritation in nearby tissue, or related complications.<ref>Against Varicocele Embolization http://againstvaricoceleembolization.org/</ref>   Scientific inquiry suggests that varicocele coil removal can resolve chronic pain post-embolization.<ref>Resolution of Abdominal Pain After Coil Embolization of Varicocele with Robotic Resection of Gonadal Vein    https://pubmed.ncbi.nlm.nih.gov/33457722/</ref>

== Prognosis ==
Whether having varicocele surgery or embolization improves male fertility is controversial, as good clinical data is lacking.<ref name=Baazeem2011/>  There is tentative evidence that varicocelectomy may improve fertility in those with obvious findings and abnormal sperm;<ref name=KupisDobronski2015/> however, this has a [[number needed to treat]] of 7 for varicocelectomy and 17 for embolization.<ref>{{Cite journal|last1=Kroese|first1=A. C. J.|last2=Lange|first2=N. M. de|last3=Collins|first3=J. A.|last4=Evers|first4=J. L. H.|date=2013-07-01|title=Varicocele surgery, new evidence|journal=Human Reproduction Update|volume=19|issue=4|page=317|doi=10.1093/humupd/dmt004|pmid=23515200|doi-access=}}</ref><ref>{{cite journal|last2=Yue|first2=Huanxun|last3=Yamaguchi|first3=Kohei|last4=Okada|first4=Keisuke|last5=Matsushita|first5=Kei|last6=Ando|first6=Makoto|last7=Chiba|first7=Koji|last8=Fujisawa|first8=Masato|year=2012|title=Effect of surgical repair on testosterone production in infertile men with varicocele: A meta-analysis|journal=International Journal of Urology|volume=19|issue=2|pages=149–54|doi=10.1111/j.1442-2042.2011.02890.x|pmid=22059526|last1=Li|first1=Fuping|s2cid=20329833}}</ref> There are also studies showing that the regular surgery has no significant effect on infertility.<ref name=Baazeem2011>{{Cite journal|last1=Baazeem|first1=Abdulaziz|last2=Belzile|first2=Eric|last3=Ciampi|first3=Antonio|last4=Dohle|first4=Gert|last5=Jarvi|first5=Keith|last6=Salonia|first6=Andrea|last7=Weidner|first7=Wolfgang|last8=Zini|first8=Armand|date=2011-10-01|title=Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair|journal=European Urology|volume=60|issue=4|pages=796–808|doi=10.1016/j.eururo.2011.06.018|pmid=21733620}}</ref>  A 2012 [[Cochrane Database of Systematic Reviews|Cochrane review]] (updated in 2021) found tentative but unclear evidence of improved fertility among males treated for varicocele.<ref>{{Cite journal|last1=Persad|first1=Emma|last2=O'Loughlin|first2=Clare Aa|last3=Kaur|first3=Simi|last4=Wagner|first4=Gernot|last5=Matyas|first5=Nina|last6=Hassler-Di Fratta|first6=Melanie Rosalia|last7=Nussbaumer-Streit|first7=Barbara|date=2021-04-23|title=Surgical or radiological treatment for varicoceles in subfertile men|journal=The Cochrane Database of Systematic Reviews|volume=2021|issue=4 |article-number=CD000479|doi=10.1002/14651858.CD000479.pub6 |pmc=8408310|issn=1469-493X|pmid=33890288}}</ref> Evidence for [[sclerotherapy]] is unclear as of 2015.<ref>{{cite journal |last1=Macleod |first1=R |last2=Biyani |first2=CS |last3=Cartledge |first3=J |last4=Eardley |first4=I |title=Varicocele. |journal=BMJ Clinical Evidence |date=13 July 2015 |volume=2015 |pmid=26168774|pmc=4500994 }}</ref>

==Epidemiology==
Around 15% to 20% of all adult males, up to 35% to 40% of men who are evaluated for male infertility, and around 80% of men who are infertile due to some other cause, have varicocele.<ref name="WhiteKimMobley2019"/><ref name=KupisDobronski2015/><ref name=Baazeem2011/>

== See also ==
* {{Portal inline|Medicine}}

==References==
{{Reflist}}

== External links ==
* [https://www.youtube.com/watch?v=6jMIn7vIIZ4 Video of a microsurgical repair of grade 3 left varicocele]

{{Medical resources
| ICD10          = {{ICD10|I|86|1|i|80}}
| ICD9           = {{ICD9|456.4}}
| ICDO           =
| OMIM           =
| MedlinePlus    = 001284
| eMedicineSubj  = radio
| eMedicineTopic = 739
| DiseasesDB     = 13731
| MeshID         = D014646
}}
{{Vascular diseases}}
{{Male diseases of the pelvis and genitals}}
{{Authority control}}

[[Category:Andrology]]
[[Category:Male genital disorders]]
[[Category:Scrotum]]
[[Category:Vascular diseases]]