A varicocele is an abnormal tortuosity and dilation of the testicular veins and the pampiniform venous plexus of the spermatic cord.
- Rare in prepubertal boys, increases with age to approximately 15% in late adolescence and healthy adult population
- 2 to 10 years old, <1%
- 11 to 14 years old, 7.8%
- 15 to 19 years old, 14.1%
- Based on World Health Organization observational study (1992), 15–20% of adult varicocele patients have fertility problems.
- Varicocele presents in 25% of men with abnormal semen analysis and 12% of men with normal semen parameters.
- Present in 35–40% of males with primary infertility
- Left-sided predominance, 90%
- No racial predilection
- Exact mechanisms have not been fully elucidated.
- May be related to physiologic changes in puberty, such as rapid testicular growth and increased testicular blood flow
- Associated with increased height and low body mass index
- Increased risk in 1st-degree relatives of patients with a varicocele
- Association between varicocele and testicular dysfunction/fertility compromise
- Impaired spermatogenesis: decreased motility, decreased density, and increased number of pathologic sperm forms; decreased total sperm count
- Ipsilateral testicular hypotrophy
- Recent data demonstrates correlation between varicocele grade and testicular hypotrophy although not observed in prior studies.
- Testicular “catch-up growth” can be seen after varicocelectomy.
- Catch-up growth can all be seen in 30–50% of patients managed conservatively.
- Potentially caused by an embryonic field defect, affecting growth of bilateral testicles
- Exact mechanisms not clearly elucidated—multiple theories:
- Hyperthermia: Varicocele increases intratesticular temperature, likely by interfering with the pampiniform plexus’ ability to provide countercurrent cooling system.
- Potential reflux of renal and adrenal metabolites, potentially causing testicular damage
- Increased production of nitric oxide and reactive oxygen species correlate with severity of varicocele.
- Endocrine abnormalities are found in subset of patients with varicocele, including low testosterone, abnormal response to gonadotropin-releasing hormone (GnRH), and impaired Leydig cell function.
Associated with anatomy of left testicular vein
- Inserts into renal vein at right angle (right testicular vein drains into vena cava)
- Incompetent or absent valves
- Left testicular vein 8 to 10 cm longer than right, with increased pressure
- Increased venous pressure from “nutcracker phenomenon”: compression of left renal vein as it passes between aorta and superior mesenteric artery
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