VARICOCELE:
Dear Sumner:
I’d like your opinion on Ralph, a 16 year old, who came to my office today complaining of a large cluster of wormy- like structures in his scrotum. From my examination, I believe this is a varicocele. It was on the left side, and I thought that the left testicle was slightly smaller than its mate. Does this need any medical attention? It does not seem to bother Ralph.
Dear Marv:
I had a good discussion with Ralph and his Dad about varicoceles and their possible significance. They were surprised to learn that about 15% of all men have varicoceles. As is the case with Ralph, most occur on the left side. This is influenced by hydraulics. The vein from the left testicle drains into the left renal vein at a right angle, whereas the vein from the right testicle has a more gradual insertion, draining directly into the vena cava. This may result in reversed flow of blood in the left testicular vein stretching and enlarging the tiny veins above the testicle. This is referred to as a varicocele.
The question you pose is, of course, the critical one: “Does Ralph’s varicocele need any medical attention?”
Ralph’s varicocele is, indeed, quite prominent, especially when he is in the standing position. As expected, when he lay down on the examining table, the varicocele was barely detectable. (This demonstration was most reassuring to Ralph.) Ralph’s left testicle is somewhat smaller than its mate. It is certainly possible that this is secondary to the varicocele, or perhaps just a variation of his anatomy. I explained that the function of the scrotum is to regulate the temperature of the testes; added heat from the varicocele can impair sperm production. (This is one of the reasons for bringing an undescended testicle into the scrotum at an early age: the other main reason being its increased potential for malignant changes. Marv, you may have noticed that the testes of many mammals are usually up in their abdomen most of the year, descending into the scrotum during mating season in the spring. Now won’t that little tid-bit of information make for good conversation at your next cocktail party?)
The main purpose of surgical intervention is to interrupt or remove the varicose veins in the scrotum in order to detour the flow of blood into normal veins. Surgery would be advisable only if there were evidence that the varicocele is causing a problem with Ralph’s fertility and the most direct way to check his fertility status is to check a semen analysis. However, since Ralph has no immediate plans for fatherhood, both he and his Dad preferred to hold off on a sperm count for now.
