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A 10-year-old boy presented with a 6-month history of a painless mass on the left side of the scrotum. The overlying skin had a bluish discoloration. The mass felt like a “bag of worms.” When the boy stood, venous varicosity could be palpated along the spermatic cord. This venous distention increased when he performed Valsalva's maneuver and decreased when he was recumbent.

A varicocele develops as a consequence of incompetence of the valves in the spermatic vein. This permits the transmission of hydrostatic venous pressure to the pampiniform plexus. The resulting distention and tortuosity of the pampiniform plexus are so obvious that a varicocele is unlikely to be confused with any other condition.

The left side is affected in approximately 90% of cases, presumably because the left pampiniform plexus and spermatic vein drain into the left renal vein, whereas the right spermatic vein drains into a lower point in the inferior vena cava. Varicoceles are usually asymptomatic; however, a large one can be painful, particularly during strenuous physical exertion.

A varicocele may lead to a low sperm count or reduced sperm motility and may interfere with fertility. If a varicocele is a suspected cause of infertility, it may be treated by surgical ligation of the spermatic vein. Although the effect of early surgical correction of a varicocele on future fertility is unknown, improved testicular growth has been reported after surgical correction in adolescents. Other indications for surgery are pain, testicular growth retardation or arrest over a 6- to 12-month period, and a marked volume disparity between the testicles.

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