Varicocele

Varicose vein

Varicose vein

A varicocele is defined as an abnormal dilatation of the veins of the pampiniform plexus which is found in the male scrotum.  The pampiniform plexus is a venous network made up of many small veins and is formed by the spermatic veins and tributaries from the epididymis vein. It is situated in the male spermatic cord along with arteries, lymph vessels, nerves and the ductus deferens.

About 15-20% of men in the general male population have varicoceles.  They occur more commonly in sub-fertile males.  Amongst men who are infertile about 40% of males are affected.  They are usually seen in younger males aged between 15-30 years but, although rare, can also appear for the first time in older males.  Varicoceles are rare in males under 10 years of age and their incidence increases with puberty.  Varicoceles are more commonly found in the left testicle than in the right testicle because of various anatomical factors. In America about 80 000 – 100 000 men undergo surgical correction of varicoceles each year.

Varicoceles occur in various sizes and they can be classified in different grades according to their size.

  • Large varicoceles
  • (Grade 3) are easily identified by inspection alone.

  • Moderate varicoceles
  • (Grade 2) are identified by palpation alone without performing the Valsalva maneuver.  (The Valsalva maneuver increases intra-abdominal pressure.)

  • Small varicoceles
  • (Grade 1) can only be identified when bearing down or performing the Valsalva maneuver to increase intra-abdominal pressure.

Causes

  1. Defective veins
  2. – the most common cause of the congestion and dilatation of the veins in the pampiniform plexus, which is known as a varicocele, is as a result of defective veins. This is a primary cause and the most common cause of varicoceles especially amongst younger males. Upward flow of blood in the veins of the pampiniform plexus is ensured by one-way valves. These prevent the backflow of blood. When these veins or valves are incompetent or the valves are absent, it causes the blood to back up and this then leads to dilatation of the veins. A cause of incompetent veins can be because of weak connective tissue which is usually genetic. The process here is similar to varicose veins seen on the legs.

  3. Kidney Tumour
  4. – dilatation of the veins occurs by compression of the veins by a nearby structure like a kidney tumour which can block blood flow out of a vein. This type of varicocele is known as a secondary varicocele because the varicocele is formed as a result of another cause. A kidney tumour should be suspected when a patient is over 40 years of age and presents with weight loss and newly developed varicoceles. Although it is routine practice for the Urologist to do a kidney ultrasound when a varicocele is detected, these tumours are very rare in young patients who have varicoceles and, in older patients other signs and symptoms of the primary tumour usually present before the varicocele is detected.

  5. Intra-abdominal Malignancy
  6. – a kidney tumour is the most common cause of a secondary varicocele but it can also be caused by any pelvic or abdominal malignancy or tumour. The varicocele develops either as a result of increased intra-abdominal pressure or because of compression of abdominal veins. This is more often the cause when a varicocele develops quickly in a male above 40 years of age. Urgent investigation is warranted in such a case.

  7. Nutcracker Syndrome
  8. – another non-malignant reason for compression of the veins in the pampiniform plexus is what happens in a condition called “Nutcracker Syndrome.” The left testicle’s blood return to the heart is via the left renal vein. In this condition the superior mesenteric vein compresses the left renal vein against the abdominal aorta causing increased pressures in the pampiniform plexus. This is also a varicocele with a secondary cause. The superior mesenteric vein and abdominal aorta forms a clamp or “nutcracker”(with a bit of imagination) around the renal vein, therefor putting direct pressure on the venous system which causes the small veins in the pampiniform plexus to dilate, causing a varicocele to form.