Aeitology

1. Dilated tortuous "varicose" veins in pampiniform plexus (which drain testis)
2. Occur in up to 15% of men, often around puberty
3. Sudden appearance in old men - underlying peritoneal disease incl renal cell carcinoma extenind into the left renal vein
4. 98% left sided
   • connects to left renal vein
   • Left renal vein can be compressed by colon, kidney tumours
   • Left renal vein frequently lacks a terminal valve which serves to try to prevent back-flow in the vein 

Approach

• As for scrotal examination

1. Inspect
   • Usually appears normal
2. Palpate
   • Varicocoele does not usually appear until patient is standing up - all scrotal examinations should include an examination of patient standing to exclude a varicocoele
   • "Bag of worms"
   • Non-transilluminable
   • Distinct from superficial ring (can get above mass)
   • May have palpable cough impulse
3. Percuss
4. Auscultate

Completion

1. Examine contralateral hemiscrotum

Treatment options

1. Non-surgical
   • Transfermoal radiological embolisation of testicular vein (spirng coil or sclerosant)
2. Surgical
   • Palomo operation - exposure of testicular artery by high retroperitoneal approach through incision above and medial to anterior superior iliac spine and ligation of all surrounding veins
   • Inguinal approach - with ligation of veins in the inguinal canal
   • Laproscopic ligation