DIVINE WORD COLLEGE OF BANGUED

BANGUED, ABRA
DEPARTMENT OF NURSING

Bachelor of Science in Nursing

In Partial Fulfillment of
the Requirements in NCM

A Case Study on
LEFT VARICOCELE

BSN 2

GROUP 1
BAGOYO, KELLY GENE B.
BALANAY, JESSICA
JUEVER, EURIJANE B.
LAGARTERA, ADELYN
GABAT, ARIES M.
GREGORIO, AILYNE B.
MERCADO, NICOLE JOY B.
MILLARE, JOLENIE
PENSAYO, STEPHANIE KEITH
QUIBAYEN, AERICA JOY
TAURO, ALDRED M.
VILLAMOR, AUBREY T.
2023
 TABLE OF CONTENTS

I. Introduction 1
II. History and Assessment
A. Patient’s Profile 6
B. Medical Health history
i. Past Medical History 7
ii. Present Medical History 7
iii. Obstetric History 7
C. Family Genogram 9
D. Physical Assessment 10
III. Anatomy and Physiology 13
IV. Pathophysiology 17
V. Laboratory Tests and Diagnostic Test 19
VI. Drug Study 24
VII. Nursing Care Plan 28
VIII. Updates 31
IX. References 33
X. Photo Documentation 34
I. INTRODUCTION

A Varicocele also known as scrotum varicose veins, is an enlargement of the

veins(pampiniform venous plexus) within the loose bag of skin that holds the testicles
(scrotum). These veins transport oxygen-depleted blood from the testicles. Varicocele
often develops during puberty and, most commonly develop on the left side of the
scrotum, this could be due to the position of the left testicular vein in which the right and
left side of the scrotum have different anatomy. However, studies suggests that
varicoceles can exist on both sides at the same time, but this is rare. (Urologycare
Foundation, 2022)

There are three grades of Varicocele, can be classified in any of the four
varicocele grades of the condition:

 Subclinical Varicocele (Grade 0)

The varicocele can only detect through an ultrasound. There are no symptoms
occurs in this grade of varicocele.
 Grade I Classification of Varicocele
The dysfunctional veins are not visible. A doctor detects these during a physical
exam while the patient performs a Valsalva maneuver. A Valsalva maneuver is a
breathing exercise. In this grade, there are no symptoms that can be experience.
Grade I varicoceles are associated with pressure type varicoceles, which develop
when the spermatic vein fills with blood.
 Grade II Classification of Varicocele
Varicoceles can be detected during a physical exam, even without the Valsalva
maneuver. Visible in standing position may become visible during a physical
exam. It starts to give uncomfortable feeling because veins are palpable.
 Grade III Classification of Varicocele
These varicoceles are often the most noticeable, as the scrotum may look or feel
like a bag of worms. Testicular pain worsens with exercise and prolonged sitting
or standing. If the grade 3 varicocele is not treated correctly, it may lead to
 complications such as testicular atrophy (the shrinking of the testicles) and male
infertility.

The most common signs of grade-3 varicocele are 1)Testicular ache, especially while
standing and during physical activities, 2)Painless testicular lumps and scrotal swellings,
3)Atrophy or the shrinking of the testicle, 4)Enlarged and twisted veins within the
scrotum, 5)Male infertility in adults, 6)Scrotum swelling, 7)Decreased testicular size in
children, 8)Severe and continuous discomfort that worsens as the day goes on, and 9)Pain
relief when lying on the back.

Beyond the diagnosis classifications, there are two types of varicocele based on
how the dysfunctional veins affect the body:

 Pressure Varicoceles – This may lead to retrograde blood pooling of the internal
spermatic vein (which carries deoxygenated blood from the testis), resulting in the
varicocele. However, there is no varicocele to the internal or external iliac vein. This
type of varicocele falls under the Grade I category.
 Shunt Varicoceles - This type may have a severe pooling of blood that results in a
large varicocele forming where damaged veins expand to the internal or external
iliac vein. This type of varicocele is under the Grades II and III categories.

The key difference between the classifications is how the varicocele affects the
internal and external iliac vein (one of three veins that drain the pelvic area of blood).

A varicocele usually occurs on the left side of the scrotum and often produces no
signs or symptoms. Possible signs and symptoms may include:

 Pain. This ache is caused by the pooling of blood in the scrotum. It usually feels
better in lying down position.
 Lump . Most lumps are soft and fluid-filled and may make the scrotum look a little
swollen
 Swelling. Varicoceles are caused by defective valves in the veins within the scrotum,
just above the testicles. When normal flow doesn't occur, the blood backs up, causing
the veins to dilate (enlarge).
  Low testosterone. Varicocele increase internal scrotal temperature and can cause
decrease of testosterone synthesis, when the testicles are not producing enough
testosterone,
 A mass in the scrotum. If a varicocele is large enough, a mass like a "bag of worms"
may be visible above the testicle.
 Differently sized testicles. The affected testicle may be noticeably smaller than the
other testicle.

The cause of a varicocele is not certain; nevertheless, researchers suggest that

there are some causes of varicoceles. It can be result from poorly functioning valves
found in veins to cause blood pools in the veins rather than circulating efficiently out of
the scrotum. Or it can be result of the larger veins moving from the testicles towards the
heart are connected differently on the left and right sides. More pressure is needed on the
left side to keep blood flowing through the veins towards the heart. If blood flows
backwards or pools in the veins, that can cause veins to swell. Rarely, swollen lymph nodes
or other masses behind the belly block blood flow. (Dr. Pawan Katti, 2023)

There are no particular risk factors known for varicoceles, however there are
studies that these factors can contribute in having varicoceles:

 Age – In most cases of Varicocele, about 15% of males, tend to form varicocele during
puberty particularly between the ages of 15 and 25 years old. It is because during
puberty, the testicles grow rapidly and need more blood delivered to them. Although
most of the blood continues to flow correctly, blood can begin to back up, creating a
varicocele. More than 90 percent of the time, they appear on the left testicle and they
mostly occur during or after puberty.
 Behavior – According to research it is found that smoking can also be a risk factor for
varicoceles, as it damages a person’s blood vessels. It is known as a major contributing
factor for varicocele development and severity of pain. In which, the toxins from
smoking had caused and were continuing to causing real damage to testicles and
testicular veins. (Shafi, H., Esmaeilzadeh, S., Delavar, M. A., Haydari, F. H.,
Mahdinejad, N., & Abedi, S.,2014)
 Sports/Activities – Research suggests that varicocele has higher risk in male athletes in
basketball, football, handball, and volleyball also those who are involved in
bodybuilding and aerobic, because when too much pressure occurs at the testicular vein
this can cause to malfunction of the veins that may block the blood to flow and lead to
form varicocele. Hariri (A, Abbarh S, Ameen A, Sabra A, Salman A, Alhulaimi Y,
Aabed M, Habous M, Madbouly K.,2019)
 Occupation –Some work or job can trigger varicocele to develop for example; farmer,
construction worker, driver etc. These type of jobs can expose oneself from the heat
much longer that may lead to heat stress. And this heat stress can contribute in toxic
blood pooling which can lead to testicular pain, particularly to varicocele.
 Family history of varicocele – Varicocele has a complex and multifactorial etiology, in
which genetic alterations and environmental factors contributed to the progression of
varicocele. It has also been demonstrated that men with a familial history of
varicoceles, especially in first-degree relatives, have an increased risk of it occurrence,
indicating that the genetic factors may contribute in the development of varicocele.
Though, there is no clear explanation on how genetic factors can be a risk factor for
having varicocele.
 Sexual Activity – There are significant factors, why sexual activity can be a risk factor
in having varicocele: 1.) Increased Volume of Blood to the Testicles: There is an
increase in testicular blood flow when it becomes aroused, have sex, and ejaculate,
accompanied by an increase in testicular blood pooling. 2.) Varicocele Toxic Blood
Pooling: Pooled blood in the testicular veins damages the veins and testicles. Blood
pooling causes local inflammation, hypersensitivity, heat stress, hyper-hydration,
oxidation, toxin build-up, hypoxia, and lack of nutrient exchange. Blood pooling is
toxic, it damages the veins, vein valves, testicles, sperm, sperm head, sperm tail, and
sperm DNA.3.) Local Inflammation: The minor rubbing & tugging from sexual activity
causes some damage and results in increased inflammation of the varicocele. 4.)
Infections & STIs: Most scrotal and penis related infections can increase blood pooling
in the testicular veins. Even mild infections can cause damage if left untreated. 5.)
Testicular Hyperthermia: Increased testicular blood flow, varicocele blood pooling, and
local inflammation disrupt the counter-current cooling mechanism of the pampiniform
plexus veins, resulting in testicular overheating.
 Having a varicocele can make it difficult for the body to regulate the temperature
of the testicles. Oxidative stress and the buildup of toxins can result. These factors may
contribute to the following complications:

 Poor testicular health. For boys going through puberty, a varicocele may inhibit
testicle growth, hormone production, and other factors related to the health and
function of the testicle. For men, a varicocele may result in gradual
shrinkage(atrophy) of the testicle due to tissue loss.

 Infertility. A varicocele doesn't necessarily cause infertility. An estimated 10% to

20% of men diagnosed with a varicocele experience difficulty fathering a child.
Among men with fertility problems, about 40% have a varicocele.

 Hormone imbalances. As the cells react to the increase in pressure, a change in

hormones can result. There may be higher levels of luteinizing hormone (LH). This
hormone is present in both men and women, but it is higher in women. There may
also be normal-to-subnormal levels of testosterone.

No treatment is required if it is asymptomatic. However, if the patient is

experiencing pain, infertility, and testicular weakness, he must undergo suitable
treatment. There are main treatment options for grade-3 varicocele, choosing each
procedure depends on factors like the severity of varicocele, the condition's symptoms
and complications, and the patient's decision to have children.
 Varicocele is found in 15% of all men worldwide. It is reported in 19–41% of men
presenting with primary infertility and in 45–81% of men with secondary infertility and
remains the most common cause of male infertility. In the Gulf region (Qatar), 43% of infertile
men were confirmed to have varicocele. It has been reported in 24% of healthy young
population in Turkey, as a similar community to Saudi Arabia. Varicocele-related pain
increases during exercise suggesting a role of exercise in its pathophysiology. Up to 30% of
athletes are diagnosed with varicocele, representing a significantly higher incidence than in the
general population, and up to 60–80% of bodybuilders are recorded as being affected. In a
study of over 1,000 males, Radojevic et al showed that varicocele prevalence was higher in
males playing basketball, football, handball, and volleyball than in sport-inactive controls
(17.05% vs 12.35%). (Shafi, H., Esmaeilzadeh, S., Delavar, M. A., Haydari, F. H., Mahdinejad,
N., & Abedi, S.,2014)
 In the Philippines, there are several surgeries already conducted for varicocele but it has
no research yet found about varicoceles in the Philippines. However, there is a conducted
research related to varicocele which the respondents are young male military applicants that
were examined before going to a service. And it was found out that there is an abnormalities in
the external genitalia, there are three grade of varicocele found in the respondents and base on
the results they are classified in three kinds of varicocele. Left varicocele is the most common
among men whereas, 281,230 (81.85%) respondents has left varicocele classified as Grade III,
106(37.72%) with left varicocele with Grade II classifications, 114(40.56%) has left varicocele

with Grade I classification. 435(14.25%) occurs bilateral varicocele with Grade III
classification, 326(12.62%) has bilateral varicocele with Grade II classification, and
125(10.75%) has bilateral varicocele with Grade I classification. While right varicocele was the
least common or rare in most cases in which, 11(3.9%) has right varicocele with Grade III
classifications, 5(2.5%) has right varicocele with Grade II classification, and 3(1.33%) has right
varicocele with Grade I classification.Therefore, the researchers suggest that the common factor
of having varicocele in younger male militaries can be due to their lifestyles, activities of daily
living and sex life. (Zerrudo, A. A., Bella, A. P., & Munoz, R. C.,1994)
II. HISTORY AND ASSESSMENT

A. PATIENT’S PROFILE

B. MEDICAL HEALTH HISTORY

i. Past Medical History

The patient received complete EP Immunization. He has experienced common

coughs, colds and flu in his lifetime. He received his first COVID-19 Vaccine on October
27, 2021. He was diagnosed with Urinary tract infection last year, January 1, 2022 by Dr.
Valera at Abra Provincial Hospital. He has no allergies on any foods and has not found
any allergies on drugs.

ii. Present Medical History

The patient started experiencing intermittent testicular pain on first week of

January. They thought that these signs are recurrent of urinary tract infection therefore
they went back to Abra Provincial Hospital for a check-up. His Admitting doctor was Dr.
Valera. The doctor ordered CBC testing. On palpation, a positive bag of worm sign was
noted, which lead to a diagnosis of Left Varicocele by Dr. Valera. The patient had
undergone varicocelectomy on February 02, at Abra Provincial Hospital.
C. FAMILY GENOGRAM
 D. nogram

E. PHYSICAL ASSESSMENT
POST-OP ASSESSMENT (DATE)
A. CEPHALOCAUDAL
1. GENERAL ASSESSMENT
 Conscious and coherent
 Responsive to all questions asked
 Mesomorphic body build

Vital Signs:
2. INTEGUMENTARY SYSTEM
Skin
 Brown colored, evenly distributed.
 Skin turgor snaps rapidly to its normal position
 (-) Excessive sweating
 (-) signs of lesions
 Temperature is in normal range
 Palms are pale
Scalp/Hair
 (-) tenderness noted upon palpation
 Hair is evenly distributed
 (-) presence of lice nits, and dandruff
 (-) signs of hair discoloration
 (-) evidence of alopecia
Finger Nails
 Nail beds are pink and white tips
 (-) Discoloration noted
 Capillary refill in about 1-3 seconds

3. HEAD AND FACE

 Normocephalic and proportionate to body size
 (-) tenderness noted upon palpation
 No evidence of bulging/masses or injuries
4. EYES
 PERRLA
 Same level with each other
 (+) Light yellow discoloration present in the sclera
 (-) discharges noted

5. EARS
 Symmetrical
 Proportionate with head and face
  (+) minimal cerumen in the ear canal
 (-) discharges present
 (-) visible lumps and lesions
 (-) diminished hearing acuity

6. NOSE
 No deformities nor deviations noted
 (-) signs of swelling
 (-) discharges
 Unimpaired sense of smell

7. MOUTH AND LIPS

 Lips closed symmetrically, no lumps
 (-) Swelling of Gums
 Tongue is centrally positioned, pink and moist
 Uvula is pink, smooth and upwardly movable
 Buccal mucosa is pink, smooth, and moist
 Complete teeth with no loose, missing chipped or broken teeth.

8. NECK
 Normal CROM
 Pain felt around the nape upon movement; pain scale rated:
 (-) Jugular distention
 (-) Palpable lumps and masses

9. CHEST/ THORAX AND LUNGS

 Respiratory rate: 27 cpm, not too deep nor shallow
 Normal breath sounds
  (-) Chest retractions
 (-) adventitious lung sounds such as wheezes, bronchus and harsh sounds
 Normal apical pulse rate:

10. ABDOMEN
 No rashes
 Umbilicus is inverted
 (+) gurgling sounds heard inside the abdomen
 (-) Abdominal distention
 Pain in RLQ is noted upon palpation; Pain scale rated: 6/10
 Surgical wound is present around the groin about 8 cm/4 inches.

11. GENITO-URINARY
 IFC present

12. UPPER EXTREMITIES

 No IV line present
 No edema noted
 Normal ROM

13. LOWER EXTREMITIES

 Surgical wound is present around the groin about 8 cm/4 inches.
 Normal ROM
 No edema noted
 Scars are noted around the knees
 Sole and dorsal surface is smooth
III. ANATOMY AND PHYSIOLOGY

IV. PATHOPHYSIOLOGY
 V. LABORATORY TESTS AND DIAGNOSTIC EXAMS

LABORATORY
Parameter Result Ref. Range Parameter Result Ref. Range

WBC 7.8 x 10^9/L 4.00 – 10.00 RBC 4. 96 x 10^12/L 4.00 - 5.50

Neu# 3.82 x 10^9/L 2.00 – 7.00 HGB 151g/L 120 – 160
Lym# 2.79 x 10^9/L 0.80 – 4.00 HCT 45.3% 40.0 - 54.0
Mon# 0.16 x 10^9/L 0.12 – 1.20 MCV 91.2fL 80.0 - 100.0
Eos# 0.39 x 10^9/L 0.02 – 0.50 MCH 30.5pg 27.0 – 34.0
Bas# 0.02 x 10^9/L 0.00 – 0.10 MCHC 334g/L 320 – 360
Neu% 53.2 % 50.0 – 70.0 RDW-CV 13.3% 11.0 – 16.0
Lym% 38.3 % 20.0 – 40.0 RDW-SD 46.6fL 35.0 – 56. 0
Mon% L 2.3 % 3.0 – 12.0 PLT H 331 x 10^9/L 100 - 300

Eos% 5.4 % 0.5 – 5.0 MPV 8.4fL 6.5 – 12.0

Bas% 0.3 % 0.0 – 1.0 PDW 16.0 9.0 – 17.0
PCT 2.78mL/L 1.08 – 2.82

Time of Analysis: 02/01/2023 14:42

 Low level of MONOCYTES indicates low level of WBC due to infection which the vein
scrotum swell and get larger that caused varicocele.

 High level of PLT indicates blood clots that form in his blood vessels due to valves in his
testicular vein don't work properly, gravity can make blood collect in the scrotum,
causing a varicocele.