The Varicocele

There are two incidences I can remember about a varicocele.

The first was when my grandfather narrated to me an incident when he was working as a newly graduated medico in a mission hospital in Kerala. A foreign doctor (missionary) was arguing with a woman who insisted that her son had a unilateral testicular swelling; but he could not find it. There was no love lost between this missionary and grandpa, I must add.

My grandfather then went to the kid and told him to stand up. After a few minutes a swelling slowly started forming. That is the sign of a varicocele.

The second was when I myself was examining a patient complaining of a testicular swelling but I could not find anything. I went to my consultant who again made the patient stand and I saw a small increase in the size f the testes. Varicocele.

The obvious question that is asked is, "On which side is a varicocele commoner, and why".

The answer is, left side. There are seven reasons for it, as mentioned in the classic text "A Textbook on Surgical Short cases" by S. Das.

1. The left testicular vein drains into the left renal vein at a right angle. Therefore there is a chance of blockage, as compared to the right testicular vein, which connects to the Inferior Vena Cava. 
2. The length of the left testicular vein is more than the right; because of the higher position of joining the renal vein and because of the lower position of the left testes. 
3. In 15% of cases the left testicular vein may actually join the IVC but in doing so, it would arch over the left renal vein hence predelicting it to obstruction. 
4. A loaded Sigmoid may press on the left testicular vein. 
5. This is a good one. The left adrenal vein also drains into the renal vein and circulating adrenaline can cause local vasoconstriction at the site of the testicular vein!
6.  If the left renal vein passes in between the Abdominal Aorta (posteriorly) and the Superior Mesentric Artery (anteriorly), then it may get compressed. 
7. Incompetent valves are more common in the left testicular vein. (You may need to cite references for this one)

Key words: examine in standing position, bag of worms, decreases spermatogenesis, cough impulse (palpation)

Hey, an interesting test. next time you see one, occlude the superficial inguinal ring with your thumb (on the side of the varicocele) and then ak him to stand up. You will see the varicocele filling up faster!

Also, while holding the testes with you thumb and fingers, ask the patient to bow down. You may feel reduced tension within the varicocele!

7 causes, 2 tests, and 1 clinching diagnosis. No one should have a problem with varicocele now!