When should patients with varicocoele be referred?
Varicocoele is present in 15% of men. The term describes a collection of enlarged veins in the scrotum. Most patients who seek a medical opinion are aged between 15 and 30 and asymptomatic. Varicocoeles may be present in up to 40% of men who present with subfertility, but although there is an association between varicocoele and impaired semen parameters most men will be able to achieve a natural conception without intervention. The precise mechanism by which varicocoeles develop is poorly understood, however the clinical condition is acknowledged to result from venous reflux. The absence of valves in the testicular veins is more common on the left side thus around 90% of varicocoeles are left sided. A thorough history and examination is essential to make a clinical diagnosis and determine the probable cause. The history should include: the amount of time the swelling has been present for; an assessment of degree of bothersome symptoms; details of previous surgery and fertility. It is important to be alert to the patient with an acutely presenting varicocoele or a solitary right-sided varicocoele as this may be the first presentation of a retroperitoneal malignancy, especially if the patient is over 40 and the varicocoele does not disappear on lying down. A full abdominal examination including the scrotum should be performed and the patient examined in supine and standing positions. The majority of varicocoeles occur in young healthy men and clinical examination alone is enough to make the diagnosis. Referral to a urologist and further investigations in most of these cases are not required and the patient should be reassured. Patients in whom an intra-abdominal malignancy is suspected or with significant pain should be referred to a urologist. All patients with a varicocoele presenting as part of a couple with fertility problems should be referred to a urologist with a specialist interest in fertility and an expert in assisted reproduction techniques and be counselled regarding the relative success rates of all options: varicocoele surgery versus assisted reproduction.
Bristol Urological Institute, Southmead Hospital, Bristol.
Jonathan
J
Aning
David
D
Gillatt
D006801:Humans; D007248:Infertility, Male / Q000209:etiology; D008297:Male; D012017:Referral and Consultation; D014646:Varicocele / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*