Varicocele: Difference between revisions

Latest revision as of 20:22, 4 June 2020

Background

Scrotal anatomy

Cross section showing the pampiniform venus plexus.

Peak incidence: onset of puberty
Dilatation of spermatic cord veins (pampiniform plexus)
- ~90% occur on left due to 90 degree turn of left testicular vein into left renal vein^[1]
- R testicular vein drains into IVC
  - If right-sided, consider inferior vena cava thrombosis
Can impair sperm production/function leading to infertility^[2]
Sudden appearance may be related to renal malignancy obstructing venous return

Clinical Features

Varicocele on left

Scrotal mass and discomfort (dullness/heaviness)
Physical exam
- "Bag of worms"
- More prominent with standing or Valsalva
- Does not trans-illuminate

Differential Diagnosis

Testicular Diagnoses

Evaluation

Testicular ultrasound showing left varicocele.

Workup

Consider UA
Consider testicular ultrasound

Diagnosis

May be clinical vs. based on ultrasound

Management

Scrotal support (for symptomatic relief)

Disposition

Discharge with urology referral
- Implications of possible subfertility should be discussed with patient by urologist

References

↑ Pryor JL, Howards SS. Varicocele. Urol Clin North Am. 1987 Aug;14(3):499-513.
↑ Kantartzi PD, Goulis CD, Goulis GD, Papadimas I. Male infertility and varicocele: myths and reality. Hippokratia. 2007;11(3):99-104.

Authors:

[1] Pryor JL, Howards SS. Varicocele. Urol Clin North Am. 1987 Aug;14(3):499-513.

[2] Kantartzi PD, Goulis CD, Goulis GD, Papadimas I. Male infertility and varicocele: myths and reality. Hippokratia. 2007;11(3):99-104.

[1]

[2]

@@ Line 1: / Line 1: @@
 ==Background==
+[[File:Figure 28 01 02.jpg|thumb|Scrotal anatomy]]
+[[File:Gray1147.png|thumb|Cross section showing the pampiniform venus plexus.]]
+[[File:Varicocele.png|thumb|]]
+*Peak incidence: onset of puberty
+*Dilatation of spermatic cord veins (pampiniform plexus)
+**~90% occur on left due to 90 degree turn of left testicular vein into left renal vein<ref>Pryor JL, Howards SS. Varicocele. Urol Clin North Am. 1987 Aug;14(3):499-513.</ref>
+**R testicular vein drains into IVC
+***If right-sided, consider inferior vena cava thrombosis
+*Can impair sperm production/function leading to infertility<ref>Kantartzi PD, Goulis CD, Goulis GD, Papadimas I. Male infertility and varicocele: myths and reality. Hippokratia. 2007;11(3):99-104.</ref>
+*Sudden appearance may be related to renal malignancy obstructing venous return
+==Clinical Features==
+[[File:Varikozele2.jpg|thumb|Varicocele on left]]
+*Scrotal mass and discomfort (dullness/heaviness)
+*Physical exam
+**"Bag of worms"
+**More prominent with standing or Valsalva
+**Does not trans-illuminate
--dilatation of pampiniform plexus and internal spermatic vein-occurs in 15-20% of all fertile males, 40% of infertile males
+==Differential Diagnosis==
+{{Testicular DDX}}
--80-90% occur on L due to anatomy
+==Evaluation==
+[[File:Trans varicocele.jpg|thumb|Testicular ultrasound showing left varicocele.]]
+===Workup===
+*Consider UA
+*Consider testicular ultrasound
--large (easily visualized), moderate (upon palpation), and small (palpable w valsalva)
+===Diagnosis===
+*May be clinical vs. based on ultrasound
--can impair sperm production/function
+==Management==
+*Scrotal support (for symptomatic relief)
--sudden appearance can be related to renal malignancy causing obstruction of venous return.
+==Disposition==
+*Discharge with urology referral
+**Implications of possible subfertility should be discussed with patient by urologist
--nutcracker syndrome - when SMA compresses L renal vein causing varicocele.
+==See Also==
+*[[Testicular Diagnoses]]
+==References==
+<references/>
-==Diagnosis==
+[[Category:Urology]]
+[[Category:Pediatrics]]
--hx: worse w standing/valsalva. feeling of dullness/heaviness. scrotal discomfort.-doppler ultrasound. vein = 3mm or larger ==Work-Up==
--physical exam  ("bag of worms"). have the pt valsalva-may cause ipsilateral testicular atrophy-ultrasound ==DDx==
--hydrocele, hematocele, spermatocele-malignancy. sertoli-leydig, testicular ca-abscess ==Treatment==
--scrotal support
--Surgical tx if palpable and continued pain, infertility. varicocelectomy. ==Disposition==
--if scrotal u/s confirm presence of only varicocele. followup as outpt w urology, non-urgent.
-==Source==
-Adapted from ....(emed, mayo, utd)
-[[Category:GU]]