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Updated: May 5 2018


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  • Overview
  • Introduction
    • A 13-year-old boy presents to the urgent care clinic and reports pain in his scrotal area. He denies any rashes or inciting trauma. The pain is dull and does not radiate anywhere. On physical exam, there is a “bag of worms” on palpation of the left scrotum. The scrotum does not transilluminate with light.
  • Introduction
    • Clinical definition
      • varicose veins in the scrotum
    • Epidemiology
      • incidence
        • 15% in adult men
        • 8-20% in adolescent boys
        • most common cause of scrotal enlargement in adult males
      • demographics
        • around puberty in adolescents
      • location
        • most often on left side
          • due to increased resistance from left gonadal vein draining into left renal vein
    • Etiology
      • primary varicocele
        • venous reflux
      • secondary varicocele
        • renal cell carcinoma causing compression to the veins
    • Pathogenesis
      • increased venous pressure causing dilated veins in the pampiniform plexus
  • Presentation
    • Symptoms
      • primary symptoms
        • dull ache in scrotum
        • feeling of heaviness in scrotum
        • may be asymptomatic
        • infertility
        • atrophy
    • Physical exam
      • standing or valsalva maneuver
        • distension on inspection
        • “bag of worms” on palpation
      • illumination test with light
        • scrotum does not transilluminate
  • Imaging
    • Ultrasound with doppler
      • indications
        • if varicocele is suspected but physical exam is inconclusive
      • findings
        • dilatation of vessels of pampiniform plexus > 2 mm
        • reflux in pampiniform plexus
      • sensitivity and specificity
        • both 100%
  • Differential
    • Hydrocele
      • positive transillumination test
    • Testicular torsion
      • abnormal cremasteric reflex
  • Treatment
    • Conservative
      • monitor with annual exams
        • indications
          • asymptomatic patients
          • no testicular hypotrophy
    • Operative
      • surgical ligation or embolization
        • indications
          • pain
          • infertility
          • delayed growth of testes
  • Complications
    • Infertility due to increased temperature
    • Testicular atrophy
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