Testis and epididymis
Nonneoplastic lesions
Varicocele

Author: Kenneth A. Iczkowski, M.D.
Deputy Editor Review: Debra Zynger, M.D.

Revised: 30 November 2018, last major update May 2018

Copyright: (c) 2002-2018, PathologyOutlines.com, Inc.

PubMed Search: Varicocele [title] testis pathology "loattrfree full text"[sb]

Cite this page: Iczkowski KA. Varicocele. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/testisvaricocele.html. Accessed December 15th, 2018.
Definition / general
  • Mass of tortuous and dilated veins of pampiniform plexus and internal testicular vein of spermatic cord
  • Occurs posterior and superior to the testis, may extend into the inguinal ring
Essential features
  • Probably due to incompetent valves of left internal spermatic vein as it empties into renal vein
  • 90% on left
  • 10% bilateral
  • Right internal spermatic vein is less often involved since it empties directly into the inferior vena cava and tends not to have incompetent valves
Epidemiology
Sites
  • Right sided varicocele is unusual; isolated right sided varicocele is associated with situs inversus, venous thrombosis or inferior vena cava compression from space occupying lesion such as soft tissue sarcoma; less commonly paraganglioma (Ann Saudi Med 2016;36:148)
  • It suggests the presence of a vascular abnormality (Urology 2015;85:e39)
Etiology
  • Most cases are idiopathic
  • Renal tumor may invade the left renal vein and block the drainage of the spermatic vein
  • Possible association with maternal exposure to diethylstilbestrol (Am J Obstet Gynecol 1981;140:186)
  • Rare association with sertoliform cystadenoma (Am J Surg Pathol 2018;42:141)
  • Kidney donation usually involves a left kidney; a study showed left pampiniform venous plexus diameter increased after kidney donation in men, suggesting that this can predispose to varicocele (Transplant Proc 2009;41:2738)
  • Can be caused by May-Thurner syndrome, which is reflux in the left spermatic vein caused by iliac vein compression between the right iliac artery and the spine [Ann Vasc Surg 2017;42:305)
  • Certain genetic and epigenetic changes are associated with varicocele (J Assist Reprod Genet 2017;34:839)
Clinical features
  • Often associated with infertility; after treatment, 40 - 55% recover fertility
  • Testicular pain may be associated with sexual activity
  • If longstanding, testicular atrophy and infertility of the affected testis may result
Diagnosis
  • Based on palpation while patient is at rest compared to during Valsalva
  • Graded based on physical exam findings:
    • Grade 1: palpable only during Valsalva
    • Grade 2: palpable at rest but not visible
    • Grade 3: visible and palpable at rest
  • Ultrasound if physical exam is inconclusive (J Ultrason 2016;16:359)
Laboratory
  • May decrease Leydig cell function, causing a lower serum testosterone, which can be improved after varicocelectomy (Urology 2013;81:1213)
Radiology description
  • Ultrasound can demonstrate vessel size, reversal of blood flow and testicular volume
Radiology images

Images hosted on other servers:

Left sided grade 3 varicocele

Color Doppler ultrasonography of varicocele

Case reports
Treatment
  • Varicocelectomy
  • Some patients have improved fertility after microsurgery, perhaps because DNA fragmentation is reduced / DNA integrity is improved (Syst Biol Reprod Med 2012;58:274)
  • Ligation or occlusion of left spermatic vein at the internal inguinal ring
  • Motile sperm were found in 11 of 19 patients after varicocele repair; testicular histology was also improved (Biomed Res Int. 2015;2015:709452)
Gross description
  • Thin walled cystically dilated membrane
Microscopic (histologic) description
  • From inside to outside, changes include (Ultrastruct Pathol 2010;34:260)
    • Narrowing or obliteration of the vein lumens
    • Segmental obliteration and occasional thrombi
    • Internal elastic lamina fragmentation and invagination of intima
    • Variable thickening of vein wall; the media contains hypertrophied smooth muscle fibers and deposition of collagen bundles (Ultrastruct Pathol 2012;36:201)
  • If a testis is included: decreased spermatogenesis in tubules with germ cell degeneration and increased Leydig cells
  • Adolescent varicocele: pathologic changes found at or soon after puberty, consisting of tubular sclerosis, premature germ cell sloughing, small vessel sclerosis and variable hypospermatogenesis (Am J Clin Pathol 1988;89:321)
Microscopic (histologic) images

Images hosted on PathOut server:

Contributed by Kenneth A. Iczkowski, M.D.

Orchiectomy specimen in a 30 year old with atrophic testis and varicocele

Positive stains
  • CD31 (stains endothelial layer)
Negative stains
Electron microscopy description
Differential diagnosis
  • Hydrocele is lined by tunica vaginalis mesothelium (calretinin+, CD31-) whereas varicocele is lined by endothelium (CD31+, calretinin-)
Board review question #1
Which of the following is not associated with varicocele?

  1. Destruction of vessel's external elastic lamina
  2. Endothelial cell damage
  3. Narrowing or obliteration of the lumen of the vein
  4. Thickening of the media by collagen deposition
Board review answer #1
A. Destruction of vessel's external elastic lamina. It is the internal elastic lamina that is destroyed
Board review question #2
In this orchiectomy specimen in a 30 year old with atrophic testis and varicocele, what is illustrated?



  1. Hematoma on the left, and vas deferens on the right
  2. Hydrocele on the left, and testis tubules on the right
  3. Spermatocele on the left, and rete testis on the right
  4. Varicocele on the left, and rete testis on the right
Board review answer #2
D. Varicocele on the left, and rete testis on the right