Bag Of Worms

We have discussed testicular issues, like Torsion and HSP associated pain in the past and we are all aware that a painful scrotal mass should be considered torsion until proven otherwise.  The common way to assess for that is with an Ultrasound.  Many times we are happy to report that there was no evidence of torsion, but then have to deal with the abnormalities that were seen.  While, to us, the finding of varicoceles is reassuring when compared to torsion, the patient may not be as satisfied.  So while Varicoceles are not emergent conditions, let’s make sure we know a little bit more than that they aren’t as bad as torsion.

Basics of Varicoceles

  • Consist of dilated and enlarged veins of the pampiniform plexus within the spermatic cord.
  • Rare to have before 10 years of age.
  • Increase in incidence between 10 – 15 years of age.  Rarely develops after age 40.
  • Occurs in 15% of adolescents.
  • 85-90% are found on the left side.

Presentation of Varicoceles

  • Varicoceles are most often asymptomatic and found incidentally during a well-child exam or sports physical.
  • Classically described as feeling like a Bag of Worms.” (These worms would be different than these bag of worms).
  • Located along the course of the spermatic cord – superior, posterior, and lateral to the testicle.
  • Actions that increase the intra-abdominal pressure (Valsalva, Standing Position), will increase the dilation of the veins.
  • Can lead to a dull ache that may cause the child to have concern and lead to subsequent ED visit.

Associated Problems of Varicoceles

  • Left-Testicular Growth Arrest
    • Unclear mechanism.
    • This is reversible in 80% of patients after surgical correction.
    • Once a varicocele has been identified, note the volume of the testicles.
  • Male-Factor Infertility
    • I know, this doesn’t sound like a big deal while the kid is a teenager… but it may become one.
    • Varicoceles are considered the most common correctable cause of male-factor infertility.

Right-Sided Varicocele Considerations

  • The great majority of varicoceles occur on the left, often attributed to the fact that the left testicular vein drains to the renal vein while the right drains to the infrarenal IVC.
  • If there is a varicocele on the right, consider obstruction of the vena cava (ex, retroperitoneal tumors, renal tumor, lymphadenopathy, or thrombus).


  • Supportive and symptomatic relief with appropriate referral to Urology.
  • Surgical repair is considered in those with:
    • Persistent Pain
    • Bilateral Varicoceles
    • A volume difference of greater than 2 mL between the two testicles.
    • Male-factor infertility
  • Often close monitoring with serial ultrasounds is used to determine the optimal plan.

Skoog SJ. Benign and Malignant Pediatric Scrotal Masses. Pediatric Clinics of North America. Oct 1997; 44(5): 1229 – 1250.

Paduch DA, Skoog SJ. Current Management of Adolescent Varicocele. Reveiws in Urology. 2001; 3(3): 120 – 133.




Sean M. Fox
Sean M. Fox
Articles: 583

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