Fig. 12.1
A clinical photograph of a child with left varicocele that feels like a bag of worms
The size of both testicles should be evaluated during palpation to detect a smaller testis.
Classification
Varicocele is classified into three grades:
Grade I: Varicocele palpable at Valsalva maneuver only.
Grade II: Varicocele palpable without the Valsalva manoeuvre.
Grade III: Visible varicocele.
Grade 0: Subclinical varicocele cannot be detected clinically and venous reflux detected on ultrasound only.
The degree of testicular atrophy directly correlates with varicocele grade.
Etiology
The etiology of varicocele is unknown and most likely multifactorial. These include:
Congenital absence of the valves in the left testicular vein.
Abnormal variations in venous drainage of the testes.
The right testicular vein drains directly into the inferior vena cava and the left testicular vein drains at a right angle into the left renal vein. This pattern predisposes to slower drainage in the left testicular vein. This may explain the high incidence of varicocele on the left side compared to the right.
The “nutcracker” phenomenon : The left renal vein is occasionally compressed between the superior mesenteric artery and the aorta. This creates higher pressure in the left testicular vein, which drains into the renal vein.
Increased length of the left testicular vein: The left vein is 8–10 cm longer than the right testicular vein.
Diagnosis
The diagnosis of varicocele is made clinically (feeling a bag of worms).
Venous reflux into the pampiniform plexus is diagnosed using Doppler color flow both in the supine and upright positions.
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