Varicocele
Varicocele
Varicocele is an abnormal enlargement of the pampiniform venous plexus, the veins that drains blood from the testicles in the scrotum.
Varicoceles are common. They can be found in 15 percent of the adult male population and around 20 percent of adolescent males. They’re more common in males aged 15 to 25 years old.
Varicoceles are associated with low sperm production and decreased sperm quality, which can cause infertility. HOWEVER, not all varicoceles are associated with low sperm count or affect sperm production. Varicoceles have also been associated with testicles failing to develop normally or shrink. But these associations may not necessarily be a causation.
Beware, varicoceles may occur due to an underlying disorder which may then require treatment. These secondary varicoceles may be due to liver cirrhosis associated with portal hypertension with splenorenal shunts, abdominal and retroperitoneal tumors including kidney cancer and retroperitoneal fibrosis, and also seen in the nutcracker phenomenon, which involves compression of the left renal vein between the superior mesenteric artery and aorta.
Pic from Mayo Clinic
Cause
In healthy veins inside the scrotum, one-way valves move the blood from the testicles to the scrotum, and then they send it back to the heart. Sometimes the blood does not move through the veins like it should and begins to pool in the vein, causing it to enlarge. Thus a varicocele develops slowly over time. This is almost the same way varicose veins occur in the legs. These are called primary varicoceles.
There are no established risk factors for developing a primary varicocele, and the exact cause is unclear.
Secondary varicoceles on the other hand occur due to an underlying disease. They include liver cirrhosis associated with portal hypertension with splenorenal shunts, abdominal and retroperitoneal tumors including kidney cancer and retroperitoneal fibrosis, and is also seen in the nutcracker phenomenon, which involves compression of the left renal vein between the superior mesenteric artery and aorta.
Symptoms
Varicoceles often have no signs or symptoms. Rarely, it might cause pain. The pain is usually a dull discomfort, increases with standing or physical exertion, especially over long period, worsens over the course of a day, is relieved when you lie on your back. Impaired fertility may be associated with varicoceles, but there is no conclusive evidence that treating varicoceles with improve fertility.
A varicocele has been described as looking like a “bag of worms.” The condition might cause a swollen testicle, usually on the left side.
Treatment
As a rule, varicoceles with no symptoms are not repaired.
Most health care providers do not believe these varicoceles cause health problems if not treated.
Varicoceles only needs treatment when:
- There is significant pain, related to the varicocele itself
- Presence of infertility due poor sperm count or abnormal semen analysis
- Change in the size of the testicle attributed to the varicocele
- High grade varicocele in a teenager, with abnormal semen analysis
The various types of intervention include:
- Microscopic varicocelectomy: With this technique, the surgeon makes a 1 cm incision above the scrotum. Using the microscope, the surgeon ligates all small veins and spare the vas deferens, testicular arteries and lymphatic drainage.
- Laparoscopic varicocelectomy: With this technique, the surgeon does key-hole incisions and perform vein ligation. Because there are fewer veins to ligate in the abdomen the procedure is shorter and takes approximately 30-40 minutes to complete.
- Percutaneous Embolization: Embolization is done by an Interventional Radiologist. Injection of contrast (dye) through a tube with x-ray guidance is used to see the source of the problem. The goal is to find all veins leading to the varicocele. Coils, plugs with or without sclerosant, are used to block the blood flow to the varicocele and scar them down. It is done either with local anesthetic or with light sedation through a very small hole in the groin or neck. The method most often lasts 45 minutes to an hour.
Results of intervention
The results of varicocele intervention vary based on the type of intervention used, which is balanced with risks and complications. It may not be completely resolved and there are chances that:
- varicocele remaining (persistence) or coming back (recurrence)
- fluid forming around the testicle (hydrocele)
- injury to the testicular artery
- chance of infection
There is a small chance surgery will not correct the problem. In rare cases, injury to the testicular artery can lead to loss of the testicle. Persistence or recurrence of the varicocele happens in less than one of ten patients who have surgery. Microscopic surgery has the lowest persistence rate or chance of varicocele coming back.
It is best that these issues are discussed with your doctor before any intervention is done.
When to see a doctor
Because a varicocele usually causes no symptoms, it often requires no treatment.
Varicoceles might be discovered during a fertility evaluation or a routine physical exam.
If you experience pain or swelling in your scrotum, discover a mass on your scrotum, notice that your testicles are different sizes, or develop a varicocele in your youth, or you’re having problems with fertility, contact your doctor. A number of conditions can cause a scrotal mass or testicular pain, some of which require immediate treatment.
In the absence of significant pain, infertility, change in the size of the testicle or a high grade varicocele in a teenager, there is no necessity to treat your varicocele.
Do not self-diagnose your varicocele. You may miss an important diagnosis or an associated disease.
Beware, varicoceles may occur due to an underlying disorder which may then require treatment. These secondary varicoceles may be due to liver cirrhosis associated with portal hypertension with splenorenal shunts, abdominal and retroperitoneal tumors including kidney cancer and retroperitoneal fibrosis, and also seen in the nutcracker phenomenon, which involves compression of the left renal vein between the superior mesenteric artery and aorta.
It is best that these issues are discussed with your doctor before any intervention is done.
Informative links:
https://www.mayoclinic.org/diseases-conditions/varicocele/symptoms-causes/syc-20378771
https://www.urologyhealth.org/urologic-conditions/varicoceles