Varicocele refers to the abnormal elongation, dilation, and tortuosity of the pampiniform venous plexus within the spermatic cord. Varicoceles can be classified as primary or secondary, with primary varicocele being more commonly observed in clinical practice. Primary varicocele is mostly seen in adolescents and young adults, with an incidence of approximately 10%–15% among men, predominantly affecting the left side.
Etiology
Primary varicocele occurs due to factors such as underdevelopment of the valves in the internal spermatic vein, or weakened smooth muscle or elastic fibers in the venous plexus wall. The significantly higher incidence of primary varicocele on the left side may be related to the fact that the left internal spermatic vein drains perpendicularly into the left renal vein, resulting in higher vascular resistance. Secondary varicocele is typically caused by retroperitoneal tumors or renal tumors compressing the internal spermatic vein, or by tumor thrombi in the inferior vena cava or renal vein, leading to impaired venous drainage.
Pathophysiology
Varicocele is one of the common causes of reduced semen quality and male infertility. It is associated with infertility in approximately 15%–40% of cases. Potential mechanisms affecting semen quality include venous congestion, elevated local temperature, CO2 accumulation in testicular tissue, and increased concentrations of catecholamines, cortisol, and prostaglandins in the blood. These factors can impair spermatogenesis in the testes. Additionally, the abundant communicating branches between the venous systems of both testes allow the unaffected testes to also be impacted, contributing to infertility.
Clinical Manifestations
In cases where primary varicocele is mild, symptoms are often absent and the condition may only be detected during physical examination. Common symptoms include a feeling of heaviness or dull pain in the affected scrotum, which is exacerbated by prolonged standing or walking and relieved or disappears when lying down.
Diagnosis
A standing examination may reveal significant relaxation and drooping of the affected scrotum compared to the unaffected side. Inspection and palpation may reveal a worm-like venous mass. During the Valsalva maneuver, increased abdominal pressure causes blood flow obstruction, making the varicosity more apparent. The venous dilation typically diminishes or disappears when lying down. If the dilation persists even while lying down, secondary causes should be suspected, warranting a thorough examination of the ipsilateral lumbar and abdominal regions, as well as imaging studies such as ultrasound, venous urography, CT, or MRI to rule out retroperitoneal tumors, renal tumors, or other compressive lesions.
Doppler ultrasound may show dilated and tortuous veins in the spermatic cord, with a diagnostic threshold generally set at a vein diameter greater than 2 mm. Doppler ultrasound can also identify the presence of venous reflux. Semen analysis may provide insight into fertility function.
Clinically, varicocele is graded into four categories based on severity:
- Subclinical: No symptoms or visible varicosity at rest or during the Valsalva maneuver, but detectable via ultrasound.
- Grade I: Varicosity is not palpable under normal conditions but can be detected during the Valsalva maneuver.
- Grade II: No obvious abnormalities in appearance, but varicosities are palpable.
- Grade III: The varicosities are clearly visible and palpable, resembling a mass of worm-like structures.
Treatment
In mild cases where semen analysis is normal, regular follow-up is recommended with semen analyses and testicular ultrasounds every 1–2 years. In cases with more severe symptoms, abnormal semen parameters, or adolescents with varicocele accompanied by reduced testicular volume, surgical intervention is required. Following surgery, some patients may experience improved semen quality and restoration of fertility. Surgical options include open inguinal or retroperitoneal high ligation of the internal spermatic vein, laparoscopic high ligation of the spermatic vein, or microsurgical spermatic vein ligation.