Varicocele
Urology
Illness script · Urology
Varicocele
Abnormal dilation of the pampiniform venous plexus within the spermatic cord, most common cause of correctable male infertility.
This illness script for Varicocele covers predisposing factors, classic presentation, mechanism, workup, management, and the clinical pivots that separate it from look-alikes—written for USMLE Step 1 and clerkship reasoning.
01
Predisposing factors
- Most common in adolescent and young adult males (15–35 years)
- Left-sided in ~85% due to left gonadal vein draining at 90° into left renal vein
- Bilateral in ~15%; isolated right-sided varicocele should raise concern for retroperitoneal mass
- Associated with infertility in ~35–40% of men presenting for fertility workup
- Tall, thin body habitus may predispose (increased venous column height)
02
Presentation
- Classically described as 'bag of worms' sensation on palpation of spermatic cord
- Dull, aching scrotal pain or heaviness that worsens with prolonged standing or Valsalva
- Often asymptomatic and found incidentally on infertility workup
- Grade I: palpable only with Valsalva; Grade II: palpable without Valsalva; Grade III: visible through scrotal skin
- Ipsilateral testicular atrophy is a key finding, especially in adolescents
- Does NOT transilluminate (distinguishes from hydrocele)
03
Pathophysiology
- Left gonadal vein has longer course and inserts perpendicularly into left renal vein → increased hydrostatic pressure
- Incompetent or absent venous valves → retrograde blood flow into pampiniform plexus
- Venous stasis raises intrascrotal temperature → impairs spermatogenesis and damages Leydig cells
- Elevated testicular temperature and oxidative stress → decreased sperm count, motility, and morphology
04
Diagnostics
- Scrotal ultrasound with Doppler is first-line: veins >3 mm with retrograde flow on Valsalva
- Physical exam in standing position with Valsalva is essential — supine exam may miss it
- Semen analysis if infertility is a concern (oligospermia, asthenospermia, teratospermia)
- New-onset right-sided varicocele in older male → urgent CT abdomen/pelvis to rule out retroperitoneal mass (e.g., RCC compressing IVC)
- Serum testosterone if testicular atrophy present
05
Management
- Observation appropriate for asymptomatic, grade I–II without fertility concern or atrophy
- Surgical ligation (varicocelectomy — subinguinal microsurgical approach preferred) is definitive treatment
- Percutaneous embolization is an alternative, less invasive option
- Indications for treatment: infertility with abnormal semen analysis, testicular atrophy (especially adolescents), or significant pain
- Post-varicocelectomy complication: hydrocele (most common), recurrence, or inadvertent arterial injury
06
Clinical pivots
How to separate this script from the look-alikes that show up on exams and on the wards.
Hydrocele
Hydrocele transilluminates and is a fluid collection; varicocele does not transilluminate and feels like 'bag of worms.'
Epididymo-orchitis
Epididymo-orchitis presents with acute onset, fever, and tender epididymis; varicocele is chronic and nontender.
Testicular torsion
Torsion presents with sudden severe pain, absent cremasteric reflex, and high-riding testicle; varicocele is gradual and non-emergent.
Spermatocele
Spermatocele is a discrete, painless cystic mass at the epididymal head; varicocele is a diffuse venous dilation along the cord.
Keep reading
Full libraryEducational use only. This illness script is a study framework, not medical advice. Confirm decisions with current guidelines and your clinical supervisors.