Varicocele and Pelvic Congestion Syndrome

Abstract

Varicocele is a commonly encountered venous disease characterized by varicosities of the pampiniform plexus secondary to gonadal vein reflux. Often found in adolescence, the incidence of varicocele is approximately 16 %, and its prevalence increases with each decade reaching 42 % in the elderly population. While most men with varicocele are asymptomatic, clinical presentations include male infertility, scrotal pain, and/or low serum testosterone level. It is estimated that 19–41 % of the infertile men present with varicocele as the only identifiable cause of infertility, and these individuals frequently manifest with testicular hypotrophy and abnormal semen parameters. The etiology of varicocele is believed to be multifactorial and includes anatomical difference in the venous drainages of the left and right gonadal veins, valvular absence or dysfunction, and venous obstruction from external compression. Varicocele generally occurs on the left side accounting for approximately 80–90 % of the cases although some authors have argued for the bilateral phenomenon of varicocele. The venous drainage of the left gonadal vein into the “high-pressure” left renal vein as well as the longer course and perpendicular insertion of the left gonadal vein may explain the predominance of the left-sided varicocele. It is estimated that up to 40 % of the population presents with congenital valvular absence. Valvular absence or dysfunction is believed to facilitate the venous reflux in the pampiniform plexus leading to the development of varicocele. However, some authors dispute this notion, based on the cadaver data showing the absence of the valves in the spermatic vein in men with and without varicocele. Although rare, compression of the left renal vein by the superior mesenteric artery as in the nutcracker syndrome can cause secondary varicocele. Isolated right varicocele is rare and necessitates further workup for retroperitoneal lymphadenopathy or renal tumors responsible for the venous obstruction.