Varicoceles are relatively common. A significant concern in men’s health, affecting approximately 15% of the male population, frequently develops during puberty. Often likened to varicose veins, varicoceles manifest within the scrotum, frequently involving the left testicle and leading to the enlargement of the veins.
What is the main cause of a varicocele?
A varicocele is a collection of enlarged veins in the scrotum, primarily around the left testicle. It usually happens when the valves on the veins let blood back up, which makes the veins in the pampiniform plexus in the spermatic cord swell and get bigger. The exact reason why some men have other don't is not known.
Can varicoceles cause problems later in life?
This condition can sometimes cause pain and fertility problems, particularly affecting sperm production and abnormal semen analysis (male infertility).
What does a varicocele feel like?
Varicocele symptoms can often be non-existent or mild. Still, when they manifest, they may present as an aching pain within the scrotum, enlargement of the veins, a noticeable discrepancy in testicle size, or slow testicular growth. The affected side of the scrotum might feel like a ‘bag of worms,’ especially when the individual is standing. The bag of worms is also felt more at the end of the day.
Are varicoceles Common?
15% of the males, however, this prevalence can be higher among specific populations, such as men undergoing fertility evaluations, where the prevalence can be as high as 40%.
Who do varicoceles affect?
Varicoceles usually occur during puberty and are more commonly diagnosed in men between 15 and 25, but they can occur at any age.
Does varicocele happen on one side?
They occur more frequently on the left side of the scrotum, attributed to the difference in venous anatomy on the left and right sides. Around 85-90% of varicoceles occur on the left side, 10% are bilateral, and a small percentage occur on the right side alone.
Varicocele impact on male reproductive system
Impaired fertility problems are a common question that men ask.
Among men presenting for infertility evaluations, the prevalence of varicoceles can be significantly higher. Studies suggest that approximately 35-40% of men with primary infertility and 80% with secondary infertility have varicoceles.
Varicoceles can indeed affect fertility, impacting sperm production and semen quality. Not all varicoceles lead to fertility issues, but when fertility is a concern, a semen analysis may be crucial to determine the extent of impairment and guide subsequent treatment options.
After varicocele repair for fertility reasons, how long will I have to wait to see if my semen quality gets better?
Generally, it is recommended to wait for at least 3 to 6 months after the procedure before assessing improvements in semen quality, as spermatogenesis (the production of sperm) takes approximately 74 days. Some studies suggest maximum improvement may be observed up to a year or more postoperatively.
Identifying Varicoceles: Diagnosis and Examination
Often, varicoceles are discovered during a routine physical exam. The doctor examines the patient’s scrotum for any swollen veins or abnormalities. During the physical exam, the urologist will ask you to perform the Valsalva maneuver (you will be asked to take a deep breath). This valsalva manoeuvre allows more blood to flow in the twisted veins, and the enlarged vein or pampiniform plexus will engorge feeling like a bag of worms.
If a varicocele is suspected, a scrotal ultrasound might be ordered. This non-invasive test uses sound waves to detect the presence of enlarged veins and assess blood flow within the scrotal veins.
I have pain with my varicocele. What can I do to ease the pain?
Pain from varicoceles can be distressing, but several ways exist to manage and relieve the discomfort. Below are some general approaches to managing pain associated with varicoceles:
1. Lifestyle Changes and Self-Care:
- Scrotal Support: Wearing supportive underwear or an athletic supporter can help relieve pain by supporting the scrotum.
- Avoiding Prolonged Standing: Long periods of standing can increase pressure in the veins of the scrotum and potentially worsen pain, so taking breaks and avoiding prolonged standing may be helpful.
- Avoiding Heavy Lifting: Heavy lifting can also increase intra-abdominal pressure and potentially worsen varicocele pain, so avoiding it may help.
2. Pain Management:
- Pain Relievers: Over-the-counter pain relievers such as paracetamol or nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can help reduce pain.
- Cold Compresses: Applying cold packs to the scrotum for short periods can also alleviate pain. It is essential to have a cloth barrier between the skin and the ice to avoid frostbite.
These measurements may not be sufficient, and you must talk to your Urologist.
How are varicoceles treated?
When treatment is required, varicocele repair is typically recommended, especially when there is evident pain, fertility problems, or testicular atrophy. Varicocele treatment options include open surgery, laparoscopic surgery, and varicocele embolization.
Varicocele Embolisation:
Varicocele embolisation is a minimally invasive, non-surgical procedure used to treat varicoceles. An interventional radiologist guides a small catheter through a vein in the groin or neck to the varicocele. Embolic agents are injected to block the blood flow to the varicocele, alleviating symptoms and potentially improving fertility. Recovery time is usually shorter compared to surgical treatments, with less associated pain. Varicocele embolization is typically chosen before varicocele surgery treatment options.
Risks and Complications (as per BAUS leaflet):
While varicocele embolisation is generally considered a safe procedure, it does carry some risks and complications. These can include infection at the catheter insertion site, bleeding or hematoma, and damage to blood vessels. There could be a reaction to the contrast material used, and there's a possibility of varicocele recurrence or persistence after the procedure.
Surgical Options:
The surgical approaches mainly focus on sealing the affected vein to reroute the blood flow into normal veins. These procedures are often performed under general anaesthesia.
Robotic varicocele ligation
It is a modern, precise surgery to treat varicoceles, using a robot to assist the surgeon. This is done under general anesthesia; minor cuts are made, and the robot is docked. Through the latest technological 3D camera, the surgeon finds the problematic veins and ties them off. Using the robot is a guarantee for precision. Usually, you can go home the same and return to normal activities quicker than other treatments.
Risks and Complications (as per BAUS):
- Infection: As with any surgical procedure, there is a risk of infection, but this is typically low.
- Hematoma: Bleeding could occur postoperatively, leading to a collection of blood (hematoma) in the scrotum.
- Recurrence or Persistence: There is a chance that the varicocele may persist or recur postoperatively, necessitating further intervention.
- Hydrocele Development: Fluid accumulation around the testicle (hydrocele) may occur due to disturbance of the lymphatic vessels.
- Arterial Injury: While care is taken to preserve arteries, inadvertent arterial injury is a rare but possible complication.
Microsurgical sub-inguinal varicocele ligation
Microsurgical sub-inguinal varicocele ligation is a precise procedure designed to alleviate the symptoms associated with varicoceles by ligating (tying off) the dilated veins, thus preventing blood flow to the varicocele while preserving arterial blood supply and lymphatic drainage.
A small incision is made just above the scrotum. The surgeon uses an operative microscope to precisely identify and dissect the dilated veins, arterial blood supply, and lymphatic vessels within the spermatic cord. The arteries and lymphatic vessels are carefully preserved to avoid damage. The dilated veins are ligated and cut to halt blood flow to the varicocele, allowing the blood to be rerouted to healthy veins.
Risks and Complications based on the british association of urological surgeons (BAUS)
- Infection: As with any surgical procedure, there is a risk of infection, but this is typically low.
- Hematoma: Bleeding could occur postoperatively, leading to a collection of blood (hematoma) in the scrotum.
- Recurrence or Persistence: There is a chance that the varicocele may persist or recur postoperatively, necessitating further intervention.
- Hydrocele Development: Fluid accumulation around the testicle (hydrocele) may occur due to disturbance of the lymphatic vessels.
- Arterial Injury: While care is taken to preserve arteries, inadvertent arterial injury is a rare but possible complication.
- Pain: Some patients may continue to experience pain postoperatively.
Do teenagers need varicocele repair?
Teenagers and their mums ask this question at every consultation. Varicocele treatment should be based on the following symptoms.
1. Symptomatic Varicoceles:
- If a teenager is experiencing symptoms such as pain or discomfort, intervention is generally recommended to alleviate symptoms.
2. Testicular Atrophy (shrinkage of the testicle):
- If there is evidence of testicular atrophy, intervention might be considered to prevent further damage and potential future fertility issues.
3. Asymptomatic Varicoceles:
- Some studies suggest watchful waiting is appropriate for asymptomatic varicoceles, especially if there are no signs of testicular atrophy or fertility impairment.
4. Fertility Concerns:
- Some studies have shown that varicocele repair can improve semen parameters in adolescents with impaired semen quality.
What do guidelines state:
- The American Urological Association (AUA) suggests that varicocele repair is indicated in symptomatic males and those with testicular atrophy, abnormal semen analysis, or infertility issues.
- However, there is limited high-quality evidence on the long-term outcomes and benefits of early intervention for asymptomatic varicoceles in adolescents.
Does a varicocele cause erectile dysfunction?
Varicoceles are primarily associated with testicular atrophy and infertility issues but are generally not considered a direct cause of erectile dysfunction (ED).
Conclusion:
Varicoceles are a common condition with varying degrees of severity and implications. Early detection, comprehensive diagnosis, appropriate treatment, and vigilant follow-up are crucial for mitigating any adverse impact, primarily related to fertility. Small veins (smaller varicoceles) are left alone; however, larger varicoceles causing trouble are addressed. Have an open conversation with your urologist
