Introduction

A varicocele is an abnormally dilated and tortuous pampiniform plexus, the venous complex that flows into the spermatic veins. Varicocele is present in 15% of the male population and not present prior to puberty (1-3). The majority of cases are thought to be due to absent or incompetent valves in the proximal internal spermatic vein with left-sided predominance linked to the higher venous pressures in the left internal spermatic venous system. The right spermatic vein enters the vena cava at an oblique angle, while the left spermatic vein enters the left renal vein at a right angle. The left venous insertion is also 8 to10 cm more cephalad than the insertion on the right. Both factors presumably increase the hydrostatic pressure within the left spermatic vein when compared with the right (1). Approximately 90% of unilateral varicoceles are left-sided, although bilateral varices may be found in 50% of patients (4, 25).

Varicocele is usually asymptomatic, but occasionally causes orchalgia. When symptomatic, varicocele causes a dull ache or heavy sensation in the testes that is typically worse at the end of the day or after prolonged standing or heavy exertion. Recumbency usually offers relief. Varicoceles are associated with impaired spermatogenesis and steroidogenesis (5-7). In a study conducted by the World Health Organization on 9043 men, the incidence was 25.4% in men with abnormal semen and 11.7% in men with normal semen (8). The majority of varicoceles are not associated with infertility. However, the prevalence of varicocele is increased in men presenting with male-factor subfertility--40% in men presenting with primary infertility and 80% in men presenting with secondary infertility suggesting a progressive decline in spermatogenesis and steroidogenesis over time if left untreated (9). Deleterious effects on the contralateral testis have also been noted (6,10). The exact mechanism of impaired fertility is unknown and probably multifactorial (11). Reversed venous blood flow in the spermatic veins disrupts the counter-current testicular temperature modulation. Zorgniotti and Macleod demonstrated increased testicular temperature associated with varies (12) and Wright et al. reported a decrease in testis temperature following varicocelectomy (13).

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