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Varicoceles

What are Varicoceles?

A varicocele is when veins become enlarged inside your scrotum (the pouch of skin that holds your testicles). These veins are called the pampiniform plexus. Out of one hundred males, ten to fifteen have varicocele. It is like getting a varicose vein in your leg.

What Happens Normally?

The male reproductive system   makes, stores, and moves sperm. The scrotum is the sac of skin that holds the testicles (testes). Sperm and the hormone testosterone are made in the testicles. Sperm mature while moving through a coiled tube (the epididymis) behind each testicle.

Sperm travel to the prostate from each epididymis using a tube called the vas deferens. When you ejaculate, seminal fluid mixes with sperm in the prostate to form semen. The semen travels through the urethra and comes out the end of your penis.

The spermatic cord holds the vas deferens and the testicular artery, which brings blood to the testicle. It also houses the pampiniform plexus, a group of veins that drains the blood from the testicles. Testes need a certain body heat that is below our core body heat for optimal sperm production, maturity and function. The body heat in the scrotum is about five degrees lower than that of the belly or pelvis. The latter is due to the presence of pampiniform plexus, which act as a countercurrent heat exchanger, cooling blood in the testicular artery before it enters the testicles. This helps keep it at the body heat needed to make good quality sperms. When these veins become enlarged such as in varicocele, overheating of the testes can lower sperm production and function leading to a lower fertility potential.

What are Varicoceles?

Varicoceles are when the pampiniform plexus veins in the scrotum become enlarged. These veins are like varicose veins (twisted, swollen veins, found in the leg.) Varicoceles form during puberty. They can grow larger and you may notice them more over time. Varicoceles are more common on the left side of the scrotum. This is because the male anatomy is not the same on both sides. Varicoceles can exist on both sides at the same time, but this is rare. About 10 to 15 boys out of 100 have a varicocele.

Most of the time, varicoceles cause no problems and are harmless. Less often varicoceles can cause pain, problems fathering a child, or one testicle to grow slower or shrink.

Symptoms

Most males with a varicocele  have no symptoms. But varicoceles are a concern for many reasons. Some may cause infertility (problems fathering a child) and slow growth of the left testicle during puberty. Varicoceles may be the cause of fertility problems in about four out of ten men who have problems fathering their first child. They may also be the cause of fertility problems in about eight out of ten men who have problems fathering a child after their first.

Causes

Many causes of varicoceles have been offered. The valves in the veins may not work well (or may be missing). If blood flow is sluggish, blood may pool in the veins. Also, the larger veins moving from the testicles towards the heart are connected differently on the left and right side. So 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 them to swell. Rarely, swollen lymph nodes or other masses behind the belly block blood flow. This can lead to sudden swelling of the scrotal veins. This is often painful.

Are Varicoceles Common?

About 15 out of 100 men have varicoceles. It’s hard to predict which of these 15 will have fertility problems caused by their varicocele. But about 4 in 10 men tested for fertility problems have a varicocele and decreased sperm movement. There’s no link with other defects, race, place of birth, or ethnic group. Though varicoceles are often found in men tested for infertility, 8 out of 10 men who have a varicocele don’t have fertility problems.

Diagnosis

Varicoceles are found through self-exam of the scrotum or during a routine doctor’s exam. They have been described as a “bag of worms” because of how they look and feel.

Urologists often check for varicoceles with the patient standing. You may be asked to take a deep breath, hold it, and bear down while your urologist feels the scrotum above the testicle. This technique is known as the “Valsalva maneuver.” It lets your urologist find any enlarged veins.

Your urologist may order a scrotal ultrasound test. Ultrasound uses sound waves to make a picture of what’s inside your body. Signs of varicoceles on ultrasound are veins that are wider than 3 millimeters with blood flowing the wrong way during the Valsalva maneuver. The ultrasound can also show the size of the testicles. These are useful in deciding how to treat teens. An ultrasound is not needed if problems are not felt during the physical exam.

Treatment

Often, varicoceles are not treated. Treatment is offered for males who have:

  • fertility problems (problems fathering a child)
  • pain
  • the left testicle growing more slowly than the right
  • Abnormal semen analysis

There are no drugs to treat or prevent varicoceles. But pain killers (such as acetaminophen or ibuprofen) may help with pain.

When needed, surgery is the main form of treatment. Embolization (briefly blocking the veins) is a non-surgical treatment option.

Surgery

There are many ways to do varicocele surgery. All involve blocking the blood flow in the pampiniform plexus veins.

Surgery

Surgery is done under general anesthesia. The two surgical approaches used most commonly are:

  • 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. The procedure takes 2 to 3 hours to complete and patient is discharged home on the same day.
  • Laparoscopic varicocelectomy: With this technique, the surgeon inserts thin tubes in the abdomen 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. Patient is discharged home on the same day.
Surgery Results

Since surgeons have started using smaller cuts through the muscle for open surgery, healing time and pain are about the same with microscopic and laparoscopic surgery. Problems after either surgery are rare. Some problems are:

  • varicocele remaining (persistence) or coming back (recurrence)
  • fluid forming around the testicle (hydrocele)
  • injury to the testicular artery

There is a small chance surgery won’t 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.

Most of the time, patients return to normal activities after 1 week with little pain.

Percutaneous Embolization

Embolization is done by an Interventional Radiologist. Injection of contrast 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. Some problems are:

  • varicocele remaining (persistence) or coming back (recurrence)
  • the coil moving from where it was placed
  • a chance of infection where the tube was placed

After Treatment

Healing after surgery is fast and pain is often mild. You should avoid exercise for 10 to 14 days. You can often return to work 5 to 7 days after surgery. You will also follow-up with your urologist. For surgery done for fertility problems, semen analysis is done three to four months later.

Healing after embolization is also relatively short with only mild pain. You should avoid exercise for 7 to 10 days after the procedure. You can often return to work one to two days later. The recurrence rate with embolization is on par with surgery. But there are cases where embolization is preferred over surgery.

The impact of varicocele repair on fertility isn’t clear. Some studies show fertility improves after varicocele repair while other studies don’t. Semen quality improves in about 6 out of 10 infertile men after varicocele repair. This treatment should be thought about along with other fertility treatment choices.

In teens, where the main reason for surgery is slow testicular growth, catch-up growth may or may not occur.

More Information

Frequently Asked Questions

What will happen if I choose not to be treated?

Majority of males with varicocele will not have problems. One out of five males with varicocele will experience difficulty fathering children. Semen analysis is highly recommended after age 16 years to determine if varicocele repair is needed. If a semen analysis is normal it is recommended to have a repeat analysis every 2 to 3 years as with time the quality of sperms may decrease. Fertility issues may come up years later, even if not seen earlier.

My teenage son was diagnosed with a varicocele. Should this be fixed?

Treatment of teens depends on each case. It’s of great value to talk about choices with a urologist or pediatric urologist. Varicocele repair in a teen may be a good choice if there is pain, if one testicle is much smaller than the other, or the teen has an abnormal semen analysis performed at age 16 years. Some choose repair so they won’t have to worry about fertility issues in the future. Semen analyses can be done in older teens to see if repair would help.

I have no symptoms, but wish to have children. Should I have my varicocele repaired?

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. If there’s worry about fertility, semen analysis can be done to see if the varicocele is harming sperm quality.

I have pain with my varicocele. What can I do to ease the pain?

Supporting the scrotum with a jockstrap or briefs-style underwear can help varicocele pain. Lying on your back helps the varicocele drain, and often eases pain. Taking pain killers (such as acetaminophen and ibuprofen) may also help. You can also talk with your urologist about varicocele repair.

I am thinking about having my varicocele repaired for fertility reasons. How long will I have to wait to see if my semen quality improves?

Semen analyses are often done three to four months after the procedure. Semen quality often improves within six months, but it may also take as long as a year.

I found a lump on my scrotum during a self-exam. Should I worry?

Abnormalities in the male reproductive tract may show up as a mass in the scrotum. Masses could be nothing to worry about and may have little effect on your health. Or they could be a sign of life-threatening illness. It’s of great value to find out what is causing your mass. One type of mass may be testicular cancer. This would be cause for concern and calls for quick action. It’s vital to see a doctor when you find any lump or bump in your testicle.

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