Extra testicular varicocele is a relatively common disorder,
which is seen as tubular serpentine structures, exceeding 2mm
in diameter, along the course of spermatic cord or the
peritesticular region, usually posterior to the testis
1. There
are several etiological causes of ETV, such as renospermatic
reflux, the “nutcracker phenomenon”, valvular insufficiency of
the left internal spermatic vein, ileospermatic reflux, neoplastic
or other retroperitoneal diseases, visceral malposition syndromes
and prior surgery in the inguinal and scrotal regions
6.
Intratesticular varicocele is a rare and relatively new
entity. It is a possible cause of male infertility. The condition is seen as either straight or serpentine hypo echoic structures
within the mediastinum testis and radiating into the testicular
parenchyma. The pathogenesis and clinical significance are not
clear7. A cut-off diameter of 2.0mm appears inappropriate
for diagnosing intratesticular varicocele. Atasoy et al.8
reported that any intratesticular venous structure that shows
reflux while the patient is standing or during Valsalva’s
maneuver should be diagnosed as an intratesticular varicocele,
regardless of the venous diameter.
The initial reports claimed that intratesticular varicoceles
are accompanied by extratesticular varicoceles. The exact
pathophysiology of intra testicular varicocele is not known.
These lesions generally occur because of retrograde blood flow
into the pampiniform plexus of the scrotum secondary to
incompetent or absent valves of internal spermatic,
cremasteric, and vasal veins. The clinical significance of this
finding is unknown. While the precise pathophysiology of
varicocele continues to be studied, temperature mediated
effects are regarded as a significant component9,10.
The most common clinical presentations of ITV are of
testicular pain (30%) and swelling (26%). The testicular pain is
thought to relate to stretching of the tunica albuginea. Other
presentations reported include infertility (22%) and
epididymorchitis (11%)11.
ITV is often associated with ipsilateral testicular atrophy
associated parenchymal abnormalities, but whether it is a cause
or a consequence of testicular atrophy remains unclear. It
usually, but not always, occurs in association with an ipsilateral
ETV.
Presence of intratesticular multicystic lesions in an
adolescent raises the possibility of teratoma and the
consideration of testis biopsy or possibly radical orchiectomy.
Another lesion in the differential diagnosis is cystic dysplasia
of the rete testis, abscess, simple cysts, and tubular ectasia. The
correct diagnosis is made on identification of multiple tubular
or oval anechoic structures greater than 2mm in diameter,
clearly within the parenchyma of the testis, in proximity to the
mediastinum testis with venous flow through the anechoic
areas on Doppler US and a positive response in flow with the
valsalva’s maneuver7,11.
The diagnosis of varicocele is important because it is the
most common correctable cause of male infertility. The
diagnosis can easily be made when palpable or visible findings
are observed but it may be rather challenging when it is
subclinical7.
Treatment methods reported are surgical intervention,
percutaneous embolization using coils or liquid sclerosing
agents4,12. ITV was treated successfully by percutaneous
sclerotheraphy13.
In conclusion, intratesticular varicocele is a rare entity. If
there is clinical suspicion of varicocele, even in the presence of
infertility or scrotal pain, Doppler US and US are the procedure
of choice to provide rapid diagnosis.
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