GU

Varicoceles

Varicoceles are nonacute testicular masses caused by dilation of the testicular veins. They typically present with dull, aching unilateral or bilateral scrotal pain. This pain commonly resolves with recumbency and has a significant left sided predominance. They are commonly associated with testicular atrophy or infertility: varicoceles have been cited as the most common surgically correctable cause of infertility in males. 

 

Incidence

  1. Approximately 15 % of males between 10-25 years of age have varicoceles. 
  2. Rare before 9 years of age and the start of puberty.
  3. Of men evaluated for infertility, 30% have varicoceles
  4. 15% of males with varicoceles seek medical advice concerning infertility

 

Etiology

No current proven etiology, although linked to the unusual venous drainage system of the left testicle. As veins from the testicle emerge, they form a system of branching vessels that is called the pampiniform plexus. This network allows for cooling of the blood that comes in through the arterial system via a counter-current heat exchange.

Hypotheses include:

  1. The left testicular vein joins the left renal vein, it has a longer journey than the right testicular vein that empties into the IVC, leading to increased hydrostatic pressure
  2. Absence of valves
  3. Increased left renal vein pressure is transmitted to the testicular vein.

 

Differential Diagnosis of testicular mass:

Must-not-miss:

  • Testicular torsion (usually acute, assoc. with pain)
  • Epididymitis (assoc with urethral discharge, erythema, and fever)
  • Acute Orchitis (testicular pain, nausea and vomiting, 3-4 days after mumps parotitis)
  • Inguinal hernia
  • Testicular cancer (painless mass, avg age at diagnosis: 32)

Benign causes of testicular mass:

  • Hydrocele (typically in infancy, resolves by 1yr, if new, look for other pathology)
  • Varicocele (“bag of worms”, left sided)
  • Spermatocele (painless cystic mass)

 

Diagnosis

  1. Often incidental finding during regular exam
  2. Adolescent may feel mass and/or experience scrotal discomfort.
  3. Physical examination- best in standing position in warm room
    1. "bag of worms"
    2. Asymmetrical scrotal contents
    3. Enlargement with Valsalva maneuver
    4. Disappears in supine position 
    5. Measure testicular volume to assess effect of varicocele on testicular growth

 

Management

  1. Who needs surgical repair? Varicoceles have been associated with decreased fertility, decreased spermatogenesis, and repaired men have increased rates of pregnancy in their partners. After surgery, 80% attain normal testicular size.
  2. Exaggerated response of FSH and LH to GnRH stimulation may be indicative of decreased gonadal function. But, this is an expensive test and needs to be repeated to see if there is progressive loss of function. 
  3. Current recommendations for surgical repair
    1. Greater than 2 ml. volume difference of left to right testicle measured by ultrasound
    2. Bilateral varicoceles
    3. Large varicoceles associated with discomfort and pain.
  4. Prior to surgery, discuss psychological aspects of varicoceles and associated issues with patient

 

References

  1. Skoog, S, et al. The Adolescent Varicocoele: What's New with an Old Problem in Young Patients. Pediatrics. 1997. 100:112-127.
  2. Nussinovitch Moshe et.al. Prevalence of Adolescent Varicocele. Archives of Pediatric and Adolescent Medicine.  July 2001
  3. Raj g. and Weiner J. Varicoceles in adolescents: When to observe , when to intervene. Contemporary Pediatrics January 2004
  4. Esposito C et al.  2000. Laparascopic treatment of pediatric varicocele:  A Multicenter Study of the Italian Society of Video Surgery in Infancy.  The Journal of Urology 163 (6): 1944-1946 
  5. Junnila, J and Lassen, P.  Testicular Masses.  The American Family Physician.  February 1998
  6. Cavanaugh, Robert M. Screening for Genitourinary Abnormalities in Adolescent Males. Pediatrics in Review 30.11 (2009): 431-438.
  7. Kumanov, Philip, Ralitsa N. Robeva, and Analia Tomova. Adolescent varicocele: who is at risk? Pediatrics 121.1 (2008): e53-e57.
  8. Borruto, Francesca Astra, et al. Laparoscopic vs open varicocelectomy in children and adolescents: review of the recent literature and meta-analysis. Journal of pediatric surgery 45.12 (2010): 2464-2469.