Prof. Giacomo Novara — Urology, University of Padova
Varicocele · Acute scrotum · Spermatic cord torsion · Epididymo-orchitis
Varicocele is the abnormal dilatation and tortuosity of the veins of the pampiniform plexus, secondary to reversal of flow in the internal (more frequently) or external spermatic veins. It is the scrotal equivalent of varicose veins of the lower limbs.
The left spermatic vein drains into the left renal vein at a right angle: this creates a higher hydrostatic column and greater resistance to outflow. The right spermatic vein drains directly into the inferior vena cava at an acute angle. This anatomical asymmetry explains the marked left-sided predominance of varicocele. In large left-sided varicoceles, transverse communications (cross-communications) between the two venous systems may feed a contralateral varicocele: correcting left-sided reflux often also reduces the degree of right-sided varicocele.
The classification describes anatomical variants of the left gonadal venous drainage. The so-called "type 1" (single gonadal vein draining at right angles into the renal vein) is present in only 40% of individuals — the majority present variants with multiple veins, capsular collaterals, or duplicated renal veins. This variability is relevant for treatment planning.
Varicocele in itself is not a condition that always requires treatment. There are patients with enormously dilated veins and a normal semen analysis: I do not treat them. And patients with a small varicocele and a dismal semen analysis: I treat them. The decision criterion is the semen analysis, not the degree of dilatation.
Patient with varicocele AND dyspermia documented on semen analysis AND interest in fertility. Treatment aims to improve seminal parameters (count, motility, morphology) and the probability of pregnancy.
Varicocele with normal semen analysis → surveillance. Varicocele in minors (<14 years) → semen analysis not available; management is guided by degree of dilatation and testicular volume.
Patient with no interest in fertility → diagnosing and treating a condition whose only implications are for fertility makes no sense. Partner >40 years and/or severely compromised semen analysis → refer directly to assisted reproductive technology.
Pain from varicocele is rarely an independent indication for treatment. Pain often persists after correction. Treatment is indicated only when dyspermia is also present: if pain also improves, so much the better; if it persists, the patient has been forewarned.
Palpation of the spermatic cord during the Valsalva manoeuvre: in advanced grades (G3–G4) the veins are visible on simple inspection. In lesser grades, the classic "bag of worms" sensation is felt.
It is not sufficient to detect dilated veins: the examination must document reflux within these veins during Valsalva. Venous diameter >3 mm with confirmed reflux establishes the diagnosis. It also allows assessment of testicular volume (hypotrophy = already established damage).
The fundamental examination and primary decision criterion. Assesses count, progressive motility, and morphology of spermatozoa according to WHO criteria. Cannot be requested in minors for legal reasons.
The objective is to correct reflux in the gonadal veins to improve seminal function. Both antegrade (from below, via the scrotal route) and retrograde (from above, via an endovascular route) approaches are available.
Under local anaesthesia, a ~1.5 cm scrotal incision is made, the spermatic cord is isolated, a vein of the pampiniform plexus is cannulated, phlebography confirms the anatomy, then air (1 mL) + sclerosant agent (3–4 mL) is injected with the cord clamped distally. Outpatient procedure, duration ~10 minutes. Can treat any anatomical variant. Failure rate ~10%.
Femoral or brachial access, catheterisation of the left renal vein, cannulation of the gonadal vein, sclerotherapy from above. Efficacy comparable to the antegrade approach, but more difficult in anatomical variants with multiple gonadal veins draining separately into the renal vein.
Guidelines consider the two techniques equivalent. The antegrade scrotal approach may offer a practical advantage in complex anatomical variants, allowing all veins of the plexus to be reached regardless of their number and confluence into the renal vein.
Treatment improves sperm count, motility, and morphology. Approximately 37% of patients achieve spontaneous pregnancy; in the remainder, correction of varicocele doubles the success rate of assisted reproductive techniques compared with untreated patients. Correction is therefore also useful as preparation for ART, with the exception of cases where the partner is of advanced age or the semen analysis reveals complete azoospermia.
The acute scrotum is the scrotal equivalent of the acute abdomen: acute scrotal pain with possible swelling and erythema. Three main causes account for over 90% of cases:
Urological emergency. Progressive testicular ischaemia. Time is the critical factor: beyond 24 hours the gonad is lost. Requires immediate treatment.
Acute infective-inflammatory process of the testis and epididymis. Frequently associated with fever and urinary symptoms. Medical treatment (antibiotics).
Torsion of a functionless embryological remnant of the Wolffian duct. Clinically benign. Conservative management (analgesia).
Involuntary contraction of the cremaster muscle causes rotation of the testis on its own axis (from 180° up to 720°). This first obstructs venous outflow, then compromises arterial inflow → progressive and irreversible testicular ischaemia. The damage is proportional to the degree of torsion and the time elapsed.
A distinction is made between intravaginal torsion (the most common in young adults: the testis rotates within the tunica vaginalis) and extravaginal torsion (typical of the neonate). The predisposing factor is testicular hypermobility due to inadequate fixation of the inferior pole to the scrotal wall.
Violent pain of sudden onset (often nocturnal). No fever, no voiding symptoms. Hypermobile testis, riding higher than the contralateral side. Altered epididymo-testicular anatomical relationships if torsion is not a multiple of 360°. History of similar self-limiting episodes in the past (subtorsions).
Less abrupt onset of pain. Fever present. Urinary symptoms (dysuria, frequency). Indurated and tender epididymis. Warm and erythematous scrotum. Colour Doppler: hyperaemia.
Pain at the upper pole of the testis, less intense. Normal testis on palpation. The "blue dot" sign occasionally visible (rarely). Colour Doppler: normal intraparenchymal flow, absent flow within the appendix.
Colour Doppler ultrasound is the decisive examination. The contralateral healthy testis is always studied first to calibrate Doppler parameters, then the affected side is examined. Normal intraparenchymal flow is 1–2 mm/s.
No intratesticular vascular signal on Doppler. This is the most decisive finding. If absent compared to the contralateral side → torsion until proven otherwise.
Marked increase in Doppler signal at the epididymis and testis due to acute inflammation. Reactive hydrocele frequently associated.
Regular intraparenchymal flow. The appendix at the upper pole appears hyperechoic and devoid of vascular signal. No surgical urgency.
Mechanism: testes rotate in a lateral-to-medial direction (from the thigh towards the midline). Detorsion is performed in the opposite direction: medial-to-lateral (from the midline towards the thigh).
In practice: right testis → detorsion clockwise (as seen by the patient); left testis → detorsion counter-clockwise.
Verification: pain relief is immediate. Confirmed by colour Doppler: flow must resume, often with reactive hyperaemia.
Limitation: most effective if the patient presents within a few hours. After successful detorsion, elective orchidopexy should be planned (adult) or performed the same day (child).
Immediate attempt. If successful (pain relief + restoration of Doppler flow) → bilateral orchidopexy planned electively or on the same day.
Median scrotal incision of 3–4 cm. Opening of the tunica vaginalis, assessment of testicular viability. If viable → detorsion + bilateral orchidopexy (fixation of the inferior pole of both testes to the scrotal wall). If necrotic → orchiectomy (the necrotic testis must be removed to prevent the formation of anti-sperm autoantibodies that would damage the contralateral gonad).
Fixation must be performed on both sides: the hypermobility that caused the torsion is often bilateral. Preventing contralateral torsion is as important as saving the affected testis.
Infective-inflammatory process of the testis and epididymis. In the majority of cases the causative organism is a urinary tract or sexually transmitted pathogen.
Mild-to-moderate cases can be managed in the outpatient setting with oral therapy alone. Aggressive cases (high fever, systemic signs, scrotal cellulitis) require hospitalisation and parenteral therapy.
The appendix testis (Morgagni hydatid) is an embryological remnant of the Wolffian duct with no functional role whatsoever. Its torsion and necrosis has no functional or reproductive clinical relevance.
Treatment: conservative. Analgesia and, where indicated, anti-inflammatory agents. Surgical exploration is not required when the colour Doppler diagnosis is certain. The appendix will resorb spontaneously over several weeks.