Varicocele

What is Varicocele?

A varicocele is a condition where the veins in the scrotum – the pouch of skin that holds your testicles – swell up and get larg. These veins, known as the pampiniform plexus, carry blood away from each testicle. Although varicoceles are typically painless, they are significant as they’re the most common reason found for abnormal results in semen analysis, such as having a low sperm count, decreased sperm movement, or odd sperm shape. Furthermore, varicoceles can also disrupt the normal growth of the testicles.

To better understand varicoceles, it’s helpful to know a bit about the route blood takes from the testicles. The blood starts in the testicles, moves through the pampiniform plexus, travels up through a tunnel in the groin area (known as the inguinal canal) as part of the spermatic cord and then forms into a vein. From there, it ends up in the abdomen. On the right side, the blood enters a large vein with low pressure called the inferior vena cava directly. On the left side, it connects with a vein with higher pressure, the left renal vein, which sometimes can impact the drainage of blood from the left testicle. This is why varicoceles are usually found on the left side.

Varicoceles are found in roughly 15% to 20% of all men, but among men who have trouble fathering a child, the frequency increases to around 40%. It’s not completely known how a varicocele affects the production and functionality of sperm, but there are several theories. However, it’s an established fact that there is a strong connection between varicoceles and male infertility.

Numerous studies have shown that surgically repairing varicoceles can improve sperm counts, motility, and morphology, and potentially increase the chances of successful pregnancy in men with fertility problems. Moreover, in adolescent males with noticeable (large or medium-sized) varicoceles, surgery may help to normalize hormonal levels, testicles size, and sperm characteristics.

What Causes Varicocele?

Varicoceles are believed to develop when blood flow in the internal spermatic vein, a vein found in the scrotum, is blocked and causes the vein to swell. This swelling can be felt during a physical exam of the scrotum. The body also has other ways to drain blood from the testicles, like the cremasteric and deferential veins.

Varicoceles are most often found in the left testicle, around 80-90% of the time. If a varicocele is found in the left testicle, there is a 30-40% chance that it might be in both testicles.

There are three main theories about why varicoceles happen:

1. The antireflux valve, which is where the internal spermatic vein joins the left kidney’s vein, might fail. This could cause the blood to flow backward into the testicular vein.

2. The angle at the junction of the left internal spermatic vein and the left renal vein may be a contributing factor.

3. The “Nutcracker” effect, which happens when:
– The left internal spermatic vein gets trapped between the superior mesenteric artery (the main artery supplying blood to the intestines) and the aorta (the main artery carrying blood from the heart to the rest of the body). This trapping causes the vein to squeeze and blocks the blood flow, or
– There is at least 50% compression of the left renal vein (a vein that carries blood away from the kidney) between the abdominal aorta and the superior mesenteric artery. This leads to an increased pressure in the left renal vein, causing a blockage in the left spermatic vein.

Some less common causes of varicoceles include deep vein thrombosis (a blood clot in a deep vein), renal arteriovenous malformations (abnormal connections between arteries and veins in the kidney), and thrombosis of the pampiniform plexus (a network of small veins in the testicle).

Smoking tobacco and having mutations in the gene that expresses glutathione S-transferase Mu 1 can increase a man’s risk of infertility.

If a varicocele is contributing to abnormal semen analysis, it usually causes a “stress pattern” during a microscopic examination of semen. This pattern is characterized by a low count of sperm, poor movement of the sperm and an increased number of abnormal sperm.

Risk Factors and Frequency for Varicocele

About 15% to 20% of all adult men have a health condition called varicocele and almost up to half of the men being tested for fertility issues are found to have this condition. Despite this substantial prevalence, in many instances, there’s a significant delay in assessing men for potential varicoceles during the process of evaluating infertility in couples.

At one academic center, for example, it was discovered that 18% of men referred for fertility issues after undergoing expensive assisted reproductive procedures ended up being diagnosed with varicoceles and were eligible for a relatively simple procedure known as a varicocelectomy. Interestingly, in 70% of these couples that were having trouble conceiving, no fertility issues were found with the female partner.

Signs and Symptoms of Varicocele

Varicoceles are often found during regular medical check-ups or evaluations related to infertility. Typically, they don’t cause symptoms. However, about 2% to 10% of people with varicoceles experience pain which they may describe as a dull ache, a throbbing sensation, or even a heavy feeling in the scrotum. It’s rare for the pain to be sharp or severe.

Small, soft lumps above the testicle can be a sign of varicoceles. These are usually found on the left side of the scrotum, but they can occur on the right side or on both sides. If the varicocele is large, people might describe it as feeling like a “bag of worms”.

Depending on their size, varicoceles can be identified in various ways during a doctor’s examination. Large varicoceles are easy to spot and have the characteristic “bag of worms” appearance. Medium-sized varicoceles can be found by touch or physical examination without the need for the patient to bear down, which is a specific medical maneuver involving a patient holding their breath and straining as if they were trying to force out a bowel movement. If a varicocele is small, it might only be detected when the patient bears down forcefully. Varicoceles that can’t be detected this way, known as subclinical varicoceles, can only be identified using an ultrasound scanner.

Testing for Varicocele

After your physical exam, if a varicocele (enlarged veins in the scrotum) is suspected, a high-resolution color-flow Doppler ultrasound could be used to confirm it. This ultrasound technique can show if the vessels of the pampiniform plexus (a network of tiny veins in the male reproductive system) are dilated or widened, typically 3 mm or more. This test is helpful in cases where it’s unclear if a varicocele is present. However, routine imaging isn’t always necessary for significant varicoceles.

Venography, a type of x-ray that involves injecting dye into your veins, is rarely needed. It might be useful in particular situations, like if a varicocele returns after treatment or doesn’t respond to treatment.

Thermal imaging is another non-invasive method that can be used to evaluate and confirm a suspected varicocele. This technique uses heat patterns to create an image and is painless and doesn’t involve any physical contact.

Testicular strain elastography is a new technology being studied for its potential in identifying patients with a varicocele who could potentially benefit from treatment. This method uses ultrasound to measure the stiffness of tissues in the testicles.

In past times, it was common to check for a type of kidney cancer (renal cell carcinoma) in cases of an isolated right-sided varicocele. This type of cancer can spread into the vena cava (the body’s largest vein) causing a blockage that results in the development of a varicocele. In cases where this is a possibility, a CT scan might be recommended. Certain signs such as a significant unilateral right-sided varicocele, sudden onset of the varicocele, or a non-reducing varicocele are considered suspicious for diseases of the retroperitoneum (the part of the body that contains the kidneys, pancreas, and related structures).

Recently this practice has been reassessed, as kidney cancers are quite rare and don’t warrant routine imaging. Instead, a quick ultrasound could provide an efficient, cost-effective way to identify any serious diseases in the retroperitoneum, ruling out the need for more costly, anxiety-provoking or radiation-exposing CT scans.

Treatment Options for Varicocele

Unfortunately, there are no effective medical treatments for varicoceles, a swelling in the veins that drain the testicle. If varicoceles are causing discomfort or pain, over-the-counter pain relievers and supportive underwear can be tried first. But, typically, the condition is often treated with a minor surgical procedure, which is typically done as an outpatient operation, meaning no overnight stay in the hospital is needed.

The procedure can be performed using various methods, including retroperitoneal abdominal laparoscopy, infrainguinal, subinguinal (below the groin), or intrascrotal methods. Another method, antegrade scrotal sclerotherapy, may also be used. It’s important in these surgeries to avoid the vas deferens (a tube that carries sperm) and the testicular artery to prevent complications.

An alternative to surgery, percutaneous embolization, can also be used. It’s a procedure managed by a specialist known as an interventional radiologist, who uses a catheter to block the problematic veins. While it’s less invasive than open surgery, it can be technically challenging and may be less cost-effective. It’s often used as an alternative for cases where varicoceles reoccur after surgery.

Despite the varied methods, some specialists prefer a laparoscopic approach for controlling the problematic veins where they connect near the kidney. However, this method may have a higher chance of recurrence.

Studies have shown that both open surgical and non-surgical methods usually have similar success rates and post-treatment complications. Nonetheless, rates of pregnancy after treatment seem to be higher with surgical therapies. Certain innovative surgical techniques can also be used for the operation, which allow doctors to better identify the smallest veins that might be missed or the testicular artery to avoid injury.

The surgical procedure called microsurgical subinguinal varicocelectomy is often the preferred choice due to its lower rate of varicoceles reoccurrence, fewer complications, quicker recovery, and better improvement in sperm quality and movement, leading to a higher rate of pregnancies.

The decision to proceed with the surgical treatment of a varicocele is typically based on several factors, including pain relief, reduction in testicular atrophy risk, and treating or preventing infertility. Ideal patients for this treatment usually have abnormal test results related to infertility, normal female fertility, pain linked to varicocele, detectable varicocele, and slowing testicular growth in young adult males.

If a patient has varicoceles on both sides, usually, both are fixed during the surgery. Following the surgical procedure, improvements in sperm quality generally take about 3 to 4 months to become apparent, with about 70% of patients seeing an improvement.

The decision to proceed with surgery in cases of infertility is generally not recommended for subclinical varicoceles, which do not typically affect fertility. In addition, smoking or obesity may negatively affect the results of varicocele repair surgery.

If varicoceles reoccur after a surgical procedure, it’s usually treated with a repeat procedure, which has been found to provide satisfactory results most times.

In any case, after a varicocele has been treated, a follow-up sperm analysis is typically performed about four months after the surgery, to examine the effectiveness of the treatment. Unfortunately, a global survey has shown that the treatment guidelines for varicoceles are not always followed by healthcare professionals, indicating a need for better adherence to recommended practices and more inclusive guidelines covering a variety of clinical situations.

What else can Varicocele be?

If a person has varicocele, which is a swollen vein in the scrotum, usually around the left testicle, doctors will consider several other conditions that could cause similar symptoms. These are:

• Epididymal tumors (a growth in the tube at the back of the testicle that collects and carries sperm)
• Epididymitis (inflammation of the epididymis)
• Hydrocele (swelling in the scrotum due to fluid build-up)
• Inguinal hernia (when part of the intestine or fat pushes through a weak spot in the abdominal wall near the right or left inguinal canal)
• Paratesticular tumors (tumors that grow near the testicles)
• Scrotal lipomas and liposarcomas (benign and malignant fatty tumors in the scrotum)
• Spermatocele (a fluid-filled cyst in the duct that carries sperm)
• Testicular torsion (a twisted testicle)
• Testicular tumors (a growth in the testicle)
• Trauma (an injury to the scrotum)

It’s very important that all these conditions are considered and properly tested for to make sure the correct diagnosis is made.

What to expect with Varicocele

The outlook for a condition known as varicocele, which are swollen veins in the scrotum, is fairly positive. When a varicocele is causing discomfort or pain, surgery can be an effective way to provide relief. Furthermore, for men with fertility issues who also have irregular semen parameters and clinically significant varicoceles, a notable improvement in semen quality is generally observed after the surgery.

In the case of adolescents who have large varicoceles and a small testis, undergoing a surgical procedure, known as varicocelectomy, can stimulate the normal growth of the testis and can help in preventing potential fertility issues in future.

However, for those men who are capable of fathering a child, show normal testosterone levels, and do not have any symptoms related to varicoceles, treatment is not typically necessary. There seem to be no adverse effects in such cases.

Possible Complications When Diagnosed with Varicocele

Varicoceles are a medical condition that, if left untreated, might cause discomfort and negatively influence male fertility. They can also affect the growth and size of the testes in teenagers. Surgery to treat varicoceles can sometimes lead to complications, such as blood accumulation in the scrotum, fluid-filled sacs around the testicles known as hydroceles, infections, damage to the scrotal tissue, infections of the wound, and damage to the arteries supplying the testes. This may result in shrinkage or even loss of the testicle.

Some common complications that can occur after surgery include:

• Accumulation of blood in the scrotum
• Fluid-filled sacs around the testicle (hydroceles)
• Infection
• Damage to the tissue in the scrotum
• Infections at the wound site
• Testicle shrinkage or loss (from damage to the arteries)

It’s important to note that after surgery, some patients (about 5%) may develop hydroceles. Additionally, wound infections usually become evident within the first week after surgery. The shrinkage of the testicle is rare, even if the artery supplying it is accidentally tied during surgery. This is because there are other arteries that can supply adequate blood. The chances of this can be reduced by magnifying the surgical site or performing microsurgery.

Also, in about 10% of cases, the varicocele can come back after treatment. Finally, some patients may experience scrotal pain after the surgery, which might be due to various reasons, including the reemergence of hydrocele, a painful condition known as neuralgia, injury to the tube that carries urine from the kidney to the bladder (ureter), Nutcracker syndrome, reoccurrence of varicocele, or pain referred from elsewhere.

Preventing Varicocele

If a patient is diagnosed with significant varicoceles, which are enlarged veins in the scrotum, they should be made aware of the potential harmful effects. However, if the varicocele is not causing symptoms and is only discovered during other medical examinations (what doctors call subclinical), there may not be a need to fix it through surgery. In fact, surgery isn’t necessary if the varicocele is found by chance in a man who has no symptoms and is able to have children (otherwise fertile male).

However, for younger patients (adolescents), a treatment called varicocelectomy, which is a surgical procedure to correct the varicocele, can help protect their ability to have children in the future (preserving their fertility) and allow for proper growth of the testicles. All members of the healthcare team should provide accurate and easy-to-understand information about varicoceles to the patient and his family.