Definition: Group of dilated veins in pampiniform plexus

• More common on L (15% of general population) - L gonadal vein inserts into L renal vein which refluxes/impairs drainage, while R gonadal inserts into IVC
• R-sided or rapid onset - suspect renal tumor, get imaging
• Unilateral varicocele can cause bilateral testis damage
• Most common finding in subfertile men (40%) - increased sperm temperature
• Non-palpable varicocele does not cause infertility - do not need to screen for these with US

Clinical manifestations

• Inguinal/scrotal/testicular pain
• Testicular atrophy
• Ipsilateral testicle may feel soft
• Infertility
• **hide**Semen analysis "stress pattern" - decreased motility, low sperm count, increased abnormal forms

Physical exam

• Examine in supine, standing, and standing + Valsalva
• Varicocele feels like "bag of worms"; more pronounced on Valsalva in standing position
• Grade I - small, not grossly visible, palpated only during Valsalva
• Grade II - moderate, not grossly visible, easily palpated when standing
• Grade III - large, grossly visible
• If varicocele does not decompress with supine position, especially on R side, should get imaging for pelvic/RP mass

Repair indications

• Palpable varicocele + abnormal semen analysis (concern for infertility)
• Symptomatic (e.g. pain)
• 20% with persistent pain
• Adolescent with ipislateral testis atrophy (can reverse atrophy)
• Usually cutoff of 20% compared to other side; use as longitudinal marker not one-time decision making

Surveillance indications

• Normal semen analysis and desiring fertility - semen analysis q1-2 years
• Children with normal testis size - testis measurements q year to detect decrease in size

Surgical repair 

• Open (inguinal, subinguinal, or retroperitoneal), laparoscopic (ligate retroperitoneal spermatic vein), percutaneous embolization, microsurgery (lowest rates of recurrence/hydrocele)
• Palomo approach - ligate entire spermatic cord
• Side effects: hematoma (microsurgical), hydrocele (retroperitoneal/inguinal/laparoscopic approaches, 3-8%; takes up to 2 years to develop and 1/2 require intervention)
• Repair improves semen quality in approximately 70% of men by 3-6 mo after repair.
• Follow-up: semen analysis q3 mo x 1 year or until pregnant
• **hide**If infertility was due to NOA (non-obstructive azoospermia), repair may lead to motile sperm in ejaculate for IVF
• If have had vasectomy in past (likely loss of vasal artery) would not want to do varicocelectomy - could compromise blood flow and lead to testicular atrophy
• Testicular blood supply - testicular artery, with collaterals from vasal artery and cremasteric artery

Eisenberg varicocelectomy (microsurgery)

• Small inguinal incision over external ring
• Bluntly isolate cord, place large Penrose with tongue depressor inside
• Identify testicular artery with Doppler
• Isolate veins with small blue Jake, pull through 3-0 silk and cut in half, tie each side
• Try to identify cremasteric artery/isolate that vein too
• Identify three arterial supplies at end: testicular, cremasteric, vasal