| Print Date: | June 19, 2013, 2:12 pm |
| Title | Bilateral varicoceles, the left more extensive than the right |
| Text | Varicoceles are collections of veins that drain the testes. These vessels are dilated veins, almost always from the pampiniform plexus. The normal testicular veins emerge from the back of the testes, receiving tributaries from the epididymis. They unite to form the convoluted mass of vessels called the pampiniform plexus. This constitutes the greatest part of the spermatic cord. The plexus continues to the area of the superficial inguinal ring, where the vessels combine into three to four veins which pass through the inguinal canal. Entering the abdomen through the deep inguinal ring, the vessels coalesce to form two vessels that ascend on the psoas major muscle. These two veins unite to form single testicular veins, one on each side, which continue up to the level of the renal veins. The right testicular vein inserts directly into the inferior vena cava at an acute angle. The left testicular vein inserts into the left renal vein at a right angle. Both testicular veins have valves.
These dilated veins, the varicoceles, are not uncommon. They have been detected in 8 to 15% of the normal male population. The most common reason for their occurrence is incompetent valves in the testicular veins. Chronic stasis is also a cause in some cases. Abnormalities of the pelvis and retroperitoneum may also infrequently cause enlargement of these veins. Most cases of varicoceles are benign. While bilateral varicoceles are not uncommon, if unilateral varicoceles are detected, they are almost always from the left side. This is felt to be secondary to the anatomic flow of the left testicular vein into the left renal vein at a right angle. The right side is protected by the acute angle of insertion of the right testicular vein into the inferior vena cava. Nevertheless, unilateral varicoceles, on either the left or the right side, should be evaluated somewhat carefully. On the left, a search for a left- sided retroperitoneal or pelvic abnormality, including a left renal carcinoma with extension of tumor into the left renal vein, should be looked for. If the variococeles are only on the right, an anatomic variant such as a left-sided vena cava or an abdominal or pelvic mass, should also be sought. Varicoceles have been implicated as a cause of infertility or subfertility in men. It has been shown that up to 40% of men may have varicoceles. This infertility is thought to be due to venous stasis, increased scrotal heat, and abnormal anastamoses of draining veins resulting in retrograde blood flow. Small subclinical varicoceles have been shown to have the same effect on decreased sperm motility as large veins. Ultrasound is very useful in detecting varicoceles of all sizes, either in confirming the physical examination or as an incidental discovery. In the normal pampiniform plexus, the vessels are less than 1 to 2 ml in size and are not seen. When varicoceles arise, these increased anechoic tubular serpiginous vessels can be easily identified. They are most common superior to the testes, but, when numerous, may surround the testicle, ranging in size from 2 to 10 mm. The definitive diagnosis can be made by showing that these veins increase in size or by detecting a venous flow pattern within these veins with increased abdominal pressure. Increase in size can be occasionally shown if the patient sits or stands. This accentuates the pressure on these testicular veins. A simpler and more reproducible method is to use either duplex or color Doppler and to look for a typical venous waveform. Difficulties arise in that blood flow within this plexus is usually very slow, less than 10 to 15 cm/second. When the patient is lying quietly, flow may not be detected. However, flow can be made to increase in these veins by the use of the Valsalva maneuver or, if the patient is unable to perform this, by the use of a modified maneuver where gentle pressure is placed over the lower abdomen with the palm of the hand. During the time period of increased pressure, a typical venous pattern will be detected. The differential diagnosis in these anechoic tubular structures is benign. It includes a hernia extending down from the inguinal area, any unusual cyst of the spermatic cord or epididymis, or a spermatocele. In this case, because the process is bilateral, an intra-abdominal process was not seriously considered. Nevertheless, an evaluation of both kidneys, the inferior vena cava, and the pelvis was performed to make certain that no pathology existed. |
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| Contributor | Ultrasound Learning File - © ACR (ACR Learning File®) |
| Peer Reviewer | James G. Smirniotopoulos, M.D. (Uniformed Services University) |
| Record Number | : 2184 |
| Created | 2001-05-24 13:05:57-04 |
| Modified | 2001-08-30 09:27:00-04 |
| Category: | Idiopathic or Unknown |
| Location: | Genitourinary |
| Sublocation: | Testicle |
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