Varicocsele

The male reproductive tract is responsible for the production, maturation of sperm, and delivery of sperm. This tract is a complex and highly integrated entity. Sperm are produced in the testicles and then are transported through the genital duct system to the penis and out of the urethra during ejaculation. Each component of the reproductive tract is highly specialized.

Abnormalities within the male reproductive tract may appear as scrotal masses. Masses may be of little significance or may represent life-threatening illnesses. It is necessary to follow a set course of action to determine the nature of the masses and the most appropriate treatment option. For example, testicular cancer is a source of great concern and uniformly requires prompt intervention. Other masses, such as varicoceles, can cause pain or impair reproductive function. Thus, it is important for a patient to seek prompt medical attention when he identifies a scrotal mass or abnormality while performing a testicular self examination. The following information will assist you when talking to a urologist about varicoceles.

What are varicoceles?

The spermatic cord is the structure that provides the blood supply to the testicle and contains the vas deferens which transports sperm from the testicle to the penis and urethra. The spermatic cord passes through the inguinal canal and continues into the scrotum. The pampiniform plexus is a group of interconnected veins, which drain the blood from the testicles and lies within the spermatic cord. The pampiniform plexus is believed to have an important functional role in maintaining testicular temperature in the appropriate range for sperm production. The pampiniform plexus cools blood in the testicular artery before it enters the testicles, helping to maintain an ideal testicular temperature, essential for optimal sperm production.

Varicoceles are abnormal enlargements (dilations) of the pampiniform plexus of veins within the scrotum. They are similar to varicose veins of the leg, and often form during puberty. They can become larger and thus more noticeable with time. Left-sided varicoceles are more common than right-sided varicoceles, likely due to anatomical differences between the two sides.

What can cause varicoceles?

Several causes of varicoceles have been suggested. Incompetent or absent valves within the gonadal or spermatic veins may lead to pooling of blood and the abnormal enlargement in the pampiniform plexus of veins. Additionally, the angle at which the gonadal vein enters the renal (kidney) vein may produce relatively high pressure within this venous system, leading to the swelling (dilation) of the pampiniform plexus. This explains why varicoceles are more common on the left side since the gonadal vein on the left side enters the renal vein. The right gonadal vein is not as long and does not join with the right venal vein. Rarely, enlarged lymph nodes or other abnormal masses in the retroperitoneum (the space behind the abdominal cavity) will block the gonadal veins, leading to increased pampiniform venous pressure and varicocele formation. This mechanism is only of concern when one develops a new varicocele.

How common are varicoceles?

Varicoceles are present in an estimated 15 percent of all men, whereas approximately 40 percent of men undergoing evaluation for infertility are diagnosed with this condition. No racial or ethnic groups are known to be at higher risk for development of a varicocele.

What are the symptoms of varicoceles?

Most men diagnosed with a varicocele have no symptoms, but varicoceles are important for several reasons. Varicoceles are thought to cause infertility and testicular atrophy (shrinkage). Approximately 40 percent of cases of primary male infertility and 80 percent of cases of secondary male infertility are believed to be due to varicoceles. Varicoceles rarely cause pain. When pain is present, it can vary from a dull, heavy discomfort to a sharp pain. The associated symptoms may increase with sitting, standing or physical exertion - particularly if any one of these activities occurs over long periods of time. Symptoms often progress over the course of the day, and they are typically relieved when the patient lies on his back, allowing improved drainage of the veins of the pampiniform plexus.

How are varicoceles diagnosed?

Large varicoceles can be discovered through self-examination. They may look or feel like a mass in the scrotum, and they have been described as having a "bag of worms" both because of their appearance and the way they feel. Asymptomatic varicoceles are often diagnosed on physical examination at the time of routine medical evaluation. Physicians typically diagnose varicoceles with the patient in the standing position. The patient may be asked to take in a deep breath, hold it, and bear down while the physician feels the scrotum above the testicle. This technique, known as the Valsalva maneuver, assists the physician in detecting abnormal enlargement or increased fullness of the pampiniform plexus of veins. A physician may order a scrotal ultrasound test to help make the diagnosis, particularly if the physical examination is difficult or inconclusive. Radiographic hallmarks of varicoceles on scrotal ultrasonography are veins greater than three millimeters in size with reversal of blood flow within the veins of the pampiniform plexus during the Valsalva maneuver. However, most varicoceles are diagnosed in most patients on the basis of physical examination alone. Most physicians do not believe that ultrasonography should be utilized to identify small or subclinical varicoceles since several studies have shown that "subclinical" varicoceles - those detected on the basis of ultrasound or other radiographic study alone - are usually not clinically relevant. Thus, routine radiographic screening for varicoceles in the absence of physical findings is not encouraged.

What are the treatment options for varicoceles?

Treatment of varicoceles is an appropriate consideration in some patients with infertility, pain or testicular atrophy. No medical therapies are available for either treatment or prevention; however analgesic agents may alleviate associated pain when present.

There are two main approaches to the treatment of a varicocele:

Surgical Repair: This approach involves a variety of specific techniques, but all involve ligation (obstructing) the spermatic or gonadal veins thus interrupting blood flow in the vessels of the pampiniform plexus. The surgical approaches include open surgical repairs performed through a single incision with or without the use of optical magnification (e.g., magnifying glasses or loupes or an operating microscope). Laparoscopic varicocele repair which utilizes telescopes passed through the abdominal wall are not generally used since they are thought by most to have greater potential for serious complications than standard surgical techniques without significant advantage. The open procedures are performed under a variety of anesthetics, from local to general anesthesia, whereas the laparoscopic approach is uniformly performed under a general anesthetic agent. With the advent of smaller incisions, which avoid muscle transection, the open procedures are becoming closer to the laparoscopic techniques in both speed of recovery and postoperative pain. Complications resulting from either open or laparoscopic approaches are rare, but include varicocele persistence/recurrence, hydrocele formation and injury to the testicular artery.

Percutaneous Embolization: This procedure is performed by radiologists using a special tube that is inserted into a vein in either the groin or neck. After radiographic visualization of the enlarged veins of the pampiniform plexus, coils or balloons are released to create an obstruction (blockage) in the veins. This obstruction then typically leads to interruption of blood flow within the pampiniform plexus vessels and disappearance of the varicocele. Percutaneous embolization is typically performed with intravenous sedation anesthesia and usually takes several hours to complete. Complications may include varicocele persistence/recurrence, coil migration and complications at the venous access site. This has not been widely employed in most centers.

What can be expected after treatment?

Recovery time after surgical repair is usually rapid. Pain is usually mild, and patients are asked to avoid strenuous activity for 10 to 14 days. Office work can typically be done one to two days after surgery. A follow-up visit with the urologist is scheduled. A follow-up semen analysis is obtained three to four months later if the procedure was performed to treat associated infertility. Open procedures performed with optical magnification have a low recurrence rate of approximately one percent.

Recovery time after embolization is also relatively short. Again, pain is typically mild, and patients are asked to avoid strenuous physical activity for seven to 10 days after the procedure. Patients may return to office work one to two days postoperatively. The recurrence rate with embolization is generally thought to be higher than that achievable with optical magnification. Nevertheless, there are circumstances when embolization may be preferable.

The impact of varicocele correction on fertility is not entirely clear. Some studies demonstrate improvement in fertility after varicocele repair, while other studies fail to document this change. Semen quality is improved in approximately 60 percent of infertile men undergoing correction of a varicocele, and this treatment should be considered in the context of other available treatment options as couples pursue therapy.