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Harris M. Nagler, M.D., F.A.C.S. Chair, Margaret and Sol Berger Department of Urology Chief of Academic Affairs/Graduate Medical Education


Professor of Urology Albert Einstein College of Medicine of Yeshiva University


Beth Israel Medical Center Phillips Ambulatory Care Center 10 Union Square East, Suite 3A New York, NY 10003 Tel: 212-844-8900 Fax: 212-844-8901


www.bethisraelny.org


University Hospital and Manhattan Campus for the Albert Einstein College of Medicine


or pregnancies) male infertility are believed to be due to varicoceles. Varicoceles rarely cause pain. When pain is present, it can vary, but typically causes a dull, heavy discomfort. The associated symptoms may increase with sitting, standing or physical exertion - particularly if any one of these activities occurs over long periods of time. Symptoms often progress over the course of the day, and they are typically relieved when the patient lies on his back, allowing improved drainage of the veins around the testicles.


This explains why varicoceles are more common on the left side since the testicular vein on the left side enters the renal vein. The right testicular vein is not as long and does not join with the right venal vein.


Rarely, enlarged lymph nodes or other abnormal masses in the retroperitoneum (the space behind the abdominal cavity) will block the gonadal veins, leading to increased pressure in the veins and varicocele formation. This mechanism is only of concern when one develops a new varicocele or a right varicocele is present alone. This situation is quite rare.


What are the symptoms of varicoceles? Most men diagnosed with a varicocele have no symptoms, but varicoceles are important for several reasons. Varicoceles are thought to cause infertility and testicular atrophy (shrinkage). Approximately 40 percent of cases of primary male infertility and 60 percent of cases of secondary (history of prior children


How are varicoceles diagnosed? A physical examination of the male is necessary to identify a varicocele or other causes of male factor infertility. Large varicoceles can be discovered through self- examination. They may look or feel like a mass in the scrotum, and they have been described as having a "bag of worms" both because of their appearance and the way they feel. Asymptomatic varicoceles are often diagnosed on physical examination at the time of routine medical evaluation. Physicians typically diagnose varicoceles with the patient in the standing position. The patient may be asked to take in a deep breath, hold it, and bear down while the physician feels the scrotum above the testicle. This technique, known as the Valsalva maneuver, assists the physician in detecting abnormal enlargement or increased fullness of the pampiniform plexus of veins. A physician may order a scrotal ultrasound test to help make the diagnosis, particularly if the physical examination is difficult or inconclusive. If a varicocele is present, a scrotal ultrasound will identify that veins are greater than 3 millimeters in size with reversal of blood flow within the veins of the testis during the Valsalva maneuver. However, most varicoceles are diagnosed in patients on the basis of physical examination alone. Most physicians do not believe that scrotal ultrasound should be utilized to identify small or subclinical varicoceles since several studies have shown that "subclinical" varicoceles (those detected on the basis of ultrasound or other radiographic study alone) do not as clearly affect male fertility . Thus, routine ultrasound screening for varicoceles in the absence of physical findings is not encouraged. The diagnosis of a


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