Varicocele

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A varicocele is an abnormal enlargement of the pampiniform plexus (a network of small veins in the spermatic cord). Upward flow of blood in the veins is maintained by venous valves that prevent backflow. Defective valves, or compression of the vein by a nearby structure, can cause dilation of the testicular veins near the testis, leading to the formation of a varicocele.

The cause of idiopathic varicocele is thought to be due to the anatomy of the left gonadal vein which meets the left renal vein at a 90 degree angle (the right goes into the IVC).

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Thus left sided varicoceles are more common, though they may occur bilaterally, solitary right varicoceles are rare. other causes include Nutcracker syndrome (compression of the left renal vein by the superior mesenteric artery), and renal cell carcinoma.

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Varicoceles are typically harmless though may be associated with infertility. They occur in 15-20% of all males.

Symptoms include:
dull ache or scrotal pain
heaviness
palpable or visible enlarged scrotal veins (describes as “bag of worms” feeling or appearance)
testicular atrophy

When scanning it is important to scan not only the scrotum and its contents but the inguinal canal as well including images with the patient doing a valsalva maneuver.

Normal size of the veins in the pampiniform plexus is up to 1.5 mm, some use 2 mm as the cut off for diagnosis, while others prefer 3 mm. Testicular volumes can be used to assess for atrophy. In the pediatric population Testicular growth arrest with a volume difference of more than 2 mL indicates surgical correction to prevent potential fertility issues.

The varicoceles are typically describes as mild. moderate and severe and in severe cases may invade the testis causing an intratesticular varicocele.

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