urology 38 varicocele

Varicocele

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Introduction

• Dilated, elongated & tortuous veins of the spermatic cord

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Veins of spermatic cord

• Veins draining the testis & epididymis• Veins accompanying the vas deferens• Veins of the cremasteric muscles

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Cross section showing the pampiniform plexus

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Varicocele: causes

• Idiopathic: 90% in the left side• Tall, thin male• Obstruction at the place of drainage• Retroperitoneal fibrosis• Renal cell carcinoma

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Varicocele: predilection for the left side

• The left testicular vein drains into the left renal vein at right angle whereas the right testicular vein opens into the IVC obliquely

• The total length of left testicular vein is longer than the right• In 15% of the cases the left testicular artery arches over the left renal vein• The loaded sigmoid colon may compress the left testicular vein• The left suprarenal vein drains into the left renal vein• Incompetent valves are more common in the left testicular vein• Occasionally the left renal vein may pass between abdominal aorta behind

& the superior mesenteric artery in front

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Varicocele: clinical features

• Most are asymptomatic

• If they do cause symptoms it is usually a vague or annoying discomfort

• Examination shows the typical 'bag of worms' • Heavy sensation after walking or standing

• Reduces in size in the supine position

• Varicocele is occasionally associated with infertility

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Varicocele: treatment

• Conservative

• Surgical

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Varicocele: conservative treatment

• Reassurance

• Scrotal support

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Varicocele: surgical treatment

• Varicoceles only need treatment if symptomatic• Veins can be ligated via either a scrotal or inguinal approach• Recent laparoscopic ligation has been reported• Recurrence can occur due to collateral supply via cremasteric vein

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Varicocele: surgical treatment

• Palomo operation

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Incision for an inguinal approach to varicocele repair.

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