As a rule, asymptomatic during the initial stages of the disease. In most patients with varicoceles, these valves are defective leading to pooling of venous blood in the veins. Scrotal or groin pain uncommon less than 3% of men with varicocele have pain, or dragging or heavy sensations in the scrotum. The total incidence of right varicocele was 8% by clinical examination, 39% by bmode ultrasound and reversed flow was detected by cdi in 21% of patients. Varicoceles are defined as dilation of the veins of the pampiniform plexus. It rarely appears before age 10 years, and it tends to persist throughout life if left untreated.
Because a varicocele usually causes no symptoms, it often requires no treatment. Comparative assessment of pediatric testicular volume. Simple laboratory tests, such as examination of the urine or estimation of the haemoglobin content of the blood, can be carried out by the doctor himself. The primary varicocele is almost invariably on the left side. Primary varicocele happens when the configuration of the left internal spermatic vein and the renal vein forms a highpressure blood column.
A varicocele may rarely develop if there is a blockage of larger veins higher in the tummy abdomen. Varicocele embolization is an imageguided procedure that uses a catheter to place tiny coils andor a liquid substance in a blood vessel to divert blood flow away from a varicocele. At ultrasonography, varicocele was bilateral in 87. Varicoceles occur more commonly in adolescent boys than was previously suspected. The condition might cause a swollen testicle, almost always on the left side. Pdf pathophysiology, diagnosis and treatment of varicoceles. Jan 22, 2016 a varicocele is abnormal dilation of veins located in the pampiniform plexus of the spermatic cord. A small catheter is threaded through the skin nick into a vein, usually in the groin or neck. Inspect and palpate the posterior scrotum for varicocele a bag of worms or a.
Below is a description of the various types of the condition. Almost onethird of men with infertility have an abnormal finding on the ultrasound that was not suspected during the physical examination the duplex ultrasound is currently considered the best noninvasive way to identify and confirm the presence of varicoceles. The testicular blood vessels originate in the abdomen and course down through the inguinal canal as part of the spermatic cord on their way to the testis. Written clinical examination the written clinical examination is a two 2 hour examination consisting of sixtyfive 65 multiplechoice questions. It is present in 15% of the male population, in approximately 35% of men with primary infertility and in 50% to 80% of men with secondary infertility. Varicocele scrotum varicose veins diagnosis and treatment. Finally, varicocelectomy is indicated in the child or adolescent with clinical varicocele and decreased ipsilateral testicular volume greater than 2 ml. Up to 3540 % of men with a palpable left varicocele may have bilateral varicoceles that are discovered upon examination. Childhood varicocele with normal testicular volume. A varicocele has been described as looking like a bag of worms.
Listing a study does not mean it has been evaluated by the u. Mar 20, 2008 the effect of spermatic vein embolization on prostatic hypertrophy the safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Defective valves, or compression of the vein by a nearby structure, can cause dilatation of the veins nea. The diagnosis is made by carefully palpating the scrotum during a thorough upright physical examination. Varicocele, a vascular event, is associated with infertility due to testicular damage that causes abnormal spermatogenesis in males. However, scrotal anatomy eg, thick scrotum, scarring, hydrocele in some men may make. Clinical varicoceles have been classified into three. Physical examination is an essential diagnostic tool in evaluation of a patient with a varicocele. A structured approach to performing a male genital examination, including testicular examination in an osce setting. Varicocele is much less prominent and may disappear while lying down. Used as adjunct to a physical examination to detect varicocele in men with difficult examination. Spermatic vein venography is the most widely recognized method for the diagnosis of pampiniform plexus vein reflux clinical vs. There is tentative evidence that varicocelectomy may improve fertility in those with obvious findings and abnormal sperm. Dilatated veins of the spermatic cord fig varicocele in ultrasound.
A clinical retest examination, duration of one to two hours, will be administered if required. Evaluation for varicocele requires proper room setup, environment, and systematic examination. The incidence of varicoceles in the general population when evaluated by physical examination, gray scale sonography and color doppler sonography. A testicular exam is a normal part of a mans regular checkup by his doctor.
Varicocele is an abnormal tortuosity and dilatation of the pampiniform venous plexus that results from valvular incompetence of the spermatic vein. The procedure will help to figure out the spermatic veins and the doctor will get a detailed picture of the condition. An ultrasound is not required to diagnose a varicocele. A 2004 study by gat et al suggested that up to 80 % of men with a left clinical varicocele had bilateral varicoceles revealed by noninvasive radiologic testing.
A varicocele is an enlarged vein in a males scrotum with reversed or stagnant blood flow. Long lasting benefits of treatment include testicles returning to a normal size, increased sperm count, better quality of sperm, better dna quality in sperm, and a better chance at achieving pregnancy. The patients guide to varicocele the varicocele decision. Because a varicocele rarely produces symptoms, it is not uncommon for a man not to be aware that he has one unless it causes problems with fertility or is noticed during a routine physical exam. Varicocele embolization is a minimally invasive outpatient procedure that only requires local anesthesia. Grade ii, a moderate varicocele, is palpable without valsalva and grade iii is a large varicocele that is visible without palpation 21. For some patients, a scrotal ultrasound test will be recommended by the doctor. Varicocele is the most common identifiable pathology in infertile men.
Subclinical varicoceles are present in 60% of men attending fertility clinics and 40% of normal men. Varicocele, defined by the dilatation of the venous pampiniform plexus, occurs secondary to retrograde flow via the spermatic vein due to incompetent or absent valves. The varicocele cannot usually be palpated with the patient lying down. The vast majority of adolescents with varicoceles are asymptomatic. An adult patient with a varicocele is usually asymptomatic and will typically. When symptoms do occur, they tend to be felt as a dull ache or feeling of heaviness in the testicle, which gets worse during the day, particularly in. Data from clinical examination, doppleruss, colordoppleruss and retrograde phlebography were collected for each patient. Asymptomatic varicocele with normal sperm count or azoospermia. The national collaborating center for womens health of 2005 suggests not offering surgery for men with varicocele as a fertility treatment, while the european association of urology eua still considers it controversial.
Varicocele symptoms, diagnosis and treatment bmj best. Semen analysis and specialized sperm function tests in patients with varicocele. Regardless of which option you choose, varicocele embolization or surgery, treating your varicoceles can greatly alleviate your pain and discomfort. When a suspected varicocele is not clearly palpable, the. This paper discusses whether ultrasound is superfluous in the diagnosis and differential diagnosis of varicocele or whether it is still useful and complementary. Hernia, hydroceles, testicular torsion, and varicocele. Venous distention should reduce significantly, when the patient from the standing position resumes to supine position. Prevalence of adolescent varicocele adolescent medicine. Dilation and tortuosity of the veins increase with standing and usually decrease on lying down.
The physical examination should be performed with the patient in both the recumbent and upright positions. Medicine asrm recommend treatment for clinical varicoceles when a male partner has abnormal semen parameters. The subject areas, the approximate proportion of examination questions, and the subareas assigned to. Adolescent may feel mass andor experience scrotal discomfort. Diagnosis of clinical varicocele is made by physical examination. Physical examination is the gold standard for diagnosing a varicocele. It should be emphasised that physical examination is the primary diagnostic test. Certain genetic and epigenetic changes are associated with varicocele j assist reprod genet 2017. Early detection may be important because varicocele.
Although it is accepted that varicocele exerts a negative influence on male fertility potential, the effect of varicocelectomy on the restoration of fertility in men is the subject of ongoing controversy. The man may present with concern about scrotal swelling or scrotal pain, or a varicocele may be an incidental finding on physical or ultrasonographic examination. However, us is not indicated for routine varicocele diagnosis, and physical examination remains the gold standard and should be the primary factor driving management decisions. High resolution and color flow doppler ultrasound can be useful in evaluating varicocele patients. Correlation between testicular hemodynamic and semen. Radiological tests are not able to differentiate clinical from subclinical varicoceles gra 26, 28. Varicocele embolization vs varicocele surgery azura.
History taking and physical examination is to provide residents in the urology service with the guides to interview and examine patients attending to urologic practice. A varicocele is found by physical exam while the man is standing. In most men, varicocele is just an anatomical finding of no clinical significance. A varicocele that is shown on ultrasound but cannot be felt on physical exam is called a subclinical varicocele.
The significance of clinical practice guidelines on adult. A palpable varicocele feels like a bag of worms and disappears or is very significantly reduced when the patient is recumbent. Careful physical examination of the contralateral scrotal side is essential as bilateral varicoceles are common. Traditionally when a scrotal varicocele is found, the referring clinician requests a renal ultrasound examination or the sonographer extends the examination to. Clinical presentation, evaluation, and surgical management. Varicoceles are the most common identifiable cause of male infertility worldwide. Most accurate means to measure testicular size and make comparison with contralateral testis. The patient is examined in the standing position, and the scrotum is visually inspected for distended veins, which can usually be seen on the lateral aspect of the scrotum.
A varicocele is an enlargement of the veins within the scrotum. A testicular exam may be done standing up so that the scrotum is relaxed. The examination of the condition will take place while you are standing up or lying down. Inspection and palpation of the scrotum should occur with the patient in the standing and supine positions, with and without a valsalva maneuver, in a warm room to facilitate relaxation of the cremasteric and dartos muscle fibers of the scrotum. Up to 3540% of men with a palpable left varicocele may actually have bilateral varicoceles that are discovered upon examination. Varicocele usg examination 270420123 comments varicocele is an abnormal enlargement of the vein that is in the scrotum draining the testicles. A varicocele is usually asymptomatic, but 210% of affected men may have vague dragging or heavy sensations and aching pain in the scrotum or groin. Even at that time, varicoceles were known to be associated with ipsilateral testicular atrophy, which appeared to be reversible after ligation. Physical examination best in standing position in warm room bag of worms asymmetrical scrotal contents. A scrotal varicocele is a common finding during both a scrotal clinical examination or during the course of a scrotal ultrasound examination and invariably found in the left hemiscrotum. The patient is examined in the supine and standing position in a warm room in order to facilitate scrotal muscle relaxation and carry out an accurate evaluation. The effect of spermatic vein embolization on prostatic. Most cases are idiopathic renal tumor may invade the left renal vein and block the drainage of the spermatic vein possible association with maternal exposure to diethylstilbestrol am j obstet gynecol 1981.
Varicocele is a dilatation of the pampiniform plexus of the spermatic veins in the scrotum. If you have a varicocele that causes you minor discomfort, but doesnt affect your fertility, you might try the following for pain relief. Regular control of the testicular volume in 6 months intervals until the first semen analysis is possible is good alternative to surgical treatment. The right and left varicocele may be a symptom of a retroperitoneal tumor. Various studies indicate an approximate frequency of 16% table 451. Varicoceles might be discovered during a fertility evaluation or a routine physical exam.
Varicocele patients may not realize that there are two types of varicocele, and 3 grades within each type. A subclinical varicocele, or grade 0, is one not appreciated on physical exam but found serendipitously on scrotal ultrasound. Diagnosis and differential diagnosis of varicocele by. This situation is an uncommon one and tends to only occur in patients above the age of 45. Varicocele is an abnormal enlargment of the veins in the scrotum draining the testicles. The interpretation of clinical data provides the plan for further evaluation of patients. Clinical examination of the scrotum remains the most commonly used technique to diagnose varicoceles. For most patients referred to hospital, more elaborate special investigations are necessary, such as radiological examination and special. Leftsided varicoceles are 10 times more common than rightsided ones classification, clinical features, and diagnosis of inguinal and femoral hernias in adults view in chinese.
Whether having varicocele surgery or embolization improves male fertility is controversial, as good clinical data is lacking. Clinical and angiographic examination are of greater importance, as has been shown before. Typically, the pain is throbbing in nature, is localized to the testis andor varicocele, and is worse with increased physical activity. Careful examination, with the patient standing, is the most important method of detection. Diagnosis of a varicocele scrotal ultrasound with doppler examination. The doctor checks the size and position of the testicles, and gently rolls each testicle back and forward to feel for lumps or swelling. The scrotum on the side of the varicocele hangs lower than on the normal side. The clinical view of a varicocele depends on the experience of the evaluating physician. Varicoceles are a ubiquitous finding in men for any practitioner who performs genitourinary examinations regularly. This can cause retrograde flow of venous blood, which may impair the process of spermatogenesis resulting in male infertility.
The goal of this study is to ascertain the diagnostic significance of scrotal color doppler ultrasonography cdus by measuring peak systolic value psv and resistive index ri of the arteries supplying blood to the testis and their association with semen. For example, if a varicocele suddenly develops in an older man, it may indicate a tumour of the kidney. The prevalence of varicocele varies widely within the literature which is likely attributable to differences in examination technique. Discussion varicocele is defined as the dilatation and tortousity of the pampiniform plexus of veins and the internal spermatic vein. A varicocele is an abnormal dilation of varicose veins that drain the testicle, and it can be associated with a progressive decline in testicular sperm and testosterone production. Nov 12, 2018 references to dilated and tortuous veins of the spermatic cord, now referred to as a varicocele, occurred as early as 1885. Varicocele is defined as dilated testicular veins in the scrotum, and is the most common identifiable pathology in infertile men. The total incidence of left varicocele was 70% by clinical examination, 69% by bmode ultrasound and reversed flow was detected by cdi in 50% of patients. A 2004 study by gat et al suggested that up to 80% of men with a left clinical varicocele had bilateral varicoceles revealed by noninvasive radiologic testing. Varicoceles pediatrics clerkship the university of chicago. In very rare occasions, the varicocele may develop as a result of a growth in the abdomen causing high pressures on the veins. Although varicoceles are present in 15% of the normal male population, they are found in up to 40% of patients with male infertility.
Used as adjunct to a physical exam to detect varicocele in men with difficult exam. They are found in approximately 15% of adolescent male subjects and in 30% of men evaluated for infertility. The clinical examination assesses the candidates capacity in such areas as history taking, physical examination, diagnosis, ordering and interpreting investigations, clinical management and communication with patients, their families and other healthcare workers. Varicocele, typically diagnosed on the left side through clinical examination still a pillar in its diagnosis, is increasingly being identified on the right side thanks to the use of noninvasive imaging techniques doppleruss, colordoppleruss that are becoming more and more useful in the confirmation of clinical suspicion, for the. Painless scrotal swelling on the left side 90% of varicoceles appear on the left.
Questions are based on the subject areas listed below. For quite a long time, varicocele can be completely asymptomatic, developing slowly and slowly. However, a varicocele can lead to reduced fertility or scrotal pain. A varicocele is the abnormal dilation of the internal spermatic veins and pampiniform plexus that drain blood from the testis. The male infertility best practice policy committee of the american urological society recommends that imaging studies are not indicated for the standard evaluation unless the physical examination provides inconclusive findings. In this case, it is detected when examined by a urologist for another reason for example, during a physical examination. This puts backpressure on the smaller veins in the scrotum which then enlarge dilate. Varicocelea dilemma for the urologist current concepts. However, us can be useful in particular clinical scenarios where the physical examination is limited e. Varicoceles are common and usually form during puberty, though they can also be found in adult males.