Reproductive · Year 2 · from Reproductive
Case 1: Varicocele
Clinical Image
Source: Wikipedia - Varicocele - CC BY-SA 3.0
Case Presentation
A 28-year-old male presents to the urology clinic with a 2-year history of left scrotal discomfort and heaviness that worsens with prolonged standing. He and his wife have been trying to conceive for 14 months without success. Physical examination reveals a "bag of worms" palpable in the left scrotum that is more prominent when standing and with Valsalva maneuver. The right scrotum is normal. Testicular volumes are symmetric at 20 mL bilaterally. Scrotal ultrasound with Doppler confirms a left varicocele with retrograde flow during Valsalva. Semen analysis reveals oligoasthenozoospermia: concentration 10 million/mL (normal >15 million/mL), progressive motility 25% (normal >32%), and normal morphology 5%. Serum testosterone is 380 ng/dL (normal), FSH is 6 mIU/mL (normal), and LH is 4 mIU/mL (normal). The diagnosis is grade III left varicocele with secondary infertility. Varicocelectomy is recommended, as surgical repair of varicocele in men with abnormal semen parameters can improve fertility outcomes.
Key Learning Points
- Varicoceles are dilatations of the pampiniform venous plexus and are more common on the left (90%) due to the left testicular vein draining into the left renal vein at a right angle
- Varicocele is the most common surgically correctable cause of male infertility, present in 35-40% of infertile men
- The increased testicular temperature and potentially retrograde flow of adrenal metabolites impairs spermatogenesis
- A new right-sided varicocele or one that does not decompress when supine should raise concern for retroperitoneal pathology such as a renal tumor