Varicocoeles
Key points
Pathophysiology
Lack of valves in 40%
Other proposed aetiology:
Acute angle joining to renal vein
Full sigmoid
Compression of left renal vein
Right sided varicocoele should prompt suspicion of tumour compressing IVC
Left sided varicocoeles should prompt consideration of left renal tumour
Mechanism of atrophy - counter-current heat exchange disrupted
Mechanism of infertility - Leydig cell hypoplasia + possible disruption of hypothalamus-pituitary axis due to temperature
Presentation
Pain, may have dragging sensation
'Bag of worms' appearance of scrotum
Examine abdomen for mass
Clinical classification
Dublin 1970
Sub clinical: Only on imaging
1. Palpation only on standing + Valsalva
2. Palpation on standing
3. Visible on standing
Or
Grade 1: Palpable only during Valsalva manoeuvre
Grade 2: Palpable at rest, but not visible
Grade 3: Visible and palpable at rest
USS classification - Sarteschi 1993
Procedures
Needs procedure if >2ml or >10-20% size discrepancy (Abnormal semen seen at >10%)
Interventional radiology - embolisation
Laparoscopic high ligation of testicular vessels - can inject of methylene blue to testis to identify and spare lymphatics
Complications
Hydrocoele (dude to lymphatic ligation)
Testicular atrophy
Recurrence
Meta analysis European Urology 2019 - 130 patients (7-21y old)
A significant decrease in hydrocele formation was observed in lymphatic sparing versus non-lymphatic sparing surgery (p=0.02).
Increase in testicular volume following intervention mean 1.52ml
No benefits of one technique or another e.g. IR vs surgery
Page edited by Mrs Charnjit Seehra BSc November 2024
References
Essentials of Pediatric Urology, 3rd edition, 2022, Chapter 18
de Los Reyes T, Locke J, Afshar K. Varicoceles in the pediatric population: Diagnosis, treatment, and outcomes. Can Urol Assoc J. 2017 Jan-Feb;11(1-2Suppl1):S34-S39. doi: 10.5489/cuaj.4340. PMID: 28265315; PMCID: PMC5332232.
Silay MS, et al. Treatment of Varicocele in Children and Adolescents: A Systematic Review and Meta-analysis from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel. Eur Urol. 2019 Mar;75(3):448-461. doi: 10.1016/j.eururo.2018.09.042. Epub 2018 Oct 10. PMID: 30316583.