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Clinical Summary

A varicocele forms when the veins along the spermatic cord become engorged due to valve incompetence and is usually asymptomatic. Patients may complain of a dragging sensation or heaviness of the testicle, or notice the painless mass of veins itself (bag of worms). It usually develops slowly by the third decade of life and is on the left side approximately 90% of the time.

Management and Disposition

Varicocele is generally harmless, but severe ones can affect fertility and cause testicular atrophy. Obtain an ultrasound if diagnosis is unclear. Refer to a urologist and, if symptomatic, prescribe scrotal support.

Pearls

  1. Rapid appearance or presentation on the right side or at an age greater than 40 years should raise concern for extrinsic compression from an abdominal/pelvic mass or renal tumor.

  2. Superior mesenteric artery compression of the left renal vein against the aorta (nutcracker syndrome) can present as a varicocele.

  3. Varicocele forms on the left side because the left spermatic vein anastomosis to the renal vein is at 90 degrees, whereas the right-side anastomosis is considerably less acute and goes directly to the much larger inferior vena cava.

FIGURE 8.46

Varicocele. Palpation of the nontender, twisted mass along the spermatic cord feels like a “bag of worms.” (Photo contributor: Dr. Paul Turek, www.TheTurekClinic.com.)

FIGURE 8.47

Varicocele. A varicocele that led to infertility. (Photo contributor: Sandro Esteves, MD.)

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