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