Master Varicocele with Picmonic for Physician Assistant

The pampiniform plexus is the group of veins that follows the course of the spermatic cord as it exits the scrotum. The pampiniform plexus collectively drains into the testicular vein; on the left side the testicular vein drains into the left renal vein, while on the right side the testicular veins drains directly into the IVC. When venous occlusion occurs, blood backflows into the pampiniform plexus and a varicocele forms.

Because of the left side anatomy, a varicocele is more likely to occur around the left testicle, as more opportunities arise for venous compression, such as a left-sided renal carcinoma, or a dilated superior mesenteric artery compressing the left renal vein. When venous occlusion occurs, blood backflows into the pampiniform plexus and a varicocele forms. For a right-sided varicocele to occur, a large retroperitoneal mass or fibrosis would have to directly compress the right testicular vein. Varicoceles are usually noted on the right side when bilateral varicoceles are present.

Upon inspection and palpation of the scrotum, the distended pampiniform plexus will look and feel like a bag of worms.

Due to gravity and pressure, any positional maneuver that increases venous pooling like standing or Valsalva will increase the size of the varicocele. Contrast this to hernias, which will maintain their size.

Due to gravity, any position that decreases venous pooling will decrease the size of the varicocele.

When there is blood pooling around the testicles, the increased surrounding temperature can trigger cell death within germ cells, and can lead to a decline in both testicle size and sperm production.

When there is blood pooling around the testicles, the increased surrounding temperature can trigger cell death within germ cells, and can lead to a decline in both testicle size and sperm production.

Ultrasound is an effective way of distinguishing varicocele from other scrotal pathologies, like hydroceles, spermatoceles and testicular malignancies. Another important characteristic of varicoceles is the lack of transillumination when light is held behind the scrotum. Both hydroceles and spermatoceles will transilluminate.

The color Doppler function of ultrasound machines, which shows blood movement as blue when it moves away and red when it moves toward the ultrasound probe, can be used to identify retrograde venous flow within the pampiniform plexus.

When preservation of fertility is a priority, as is often the case with young men, surgery is often recommended even if not clinically established as a first-line treatment. With ligation of the obstructed testicular vein, retrograde flow ceases and the testes can begin to recover.

Supportive therapy for varicoceles includes compression with jockstraps, ice packs, and NSAIDs for pain relief. This conservative treatment approach is recommended for older men where fertility is no longer a priority.