Varicocele, An Important Cause of Decreased Fertility In Many Young Men.

By Rita Soludo

Introduction : 

  A varicocele is a collection of dilated veins that drain one or both testicles. They are similar to varicose veins seen commonly in the legs but only in different locations. In some men these dilated veins may not be noticeable but in others they give the classical appearance referred to as the bag of worms in the scrotum.

Anatomy Of Varicocele.

A varicocele is an abnormal enlargement of the pampiniform plexus ( a network of small veins in the spermatic cord that dilated to form the varicocele )

   

These network of vein arises from the testicle or testes and follows the spermatic artery out of the scrotum which is the sac containing the testicles. It then drains into the groin technically the inguinal canal and eventually into the abdominal cavity where they unite into a single large vein called the testicular or gonadal vein. This vein drains into the large veins of the abdomen,the renal vein on the left and the largest vein called the inferior vena cava (IVC) on the right .

N.B : The right testicular vein enters the inferior vena cava at more of an acute angle than the left side enters into the renal vein.

   

Symptoms.

They are various changes that would indicate the possiblity of having varicocele, Some of which are; 

. Visible or palpable enlarged vein .

. Dragging - like or aching like scrotal pain .

. Feeling of heaviness in the testicle .

. Atropy of the testicle .

. Shrinkage of the testis .

. Low sperm count .

Causes.

1.) Dilated veins results from back pressure in the testicular vein which produces dilatation and poor flow through the network of veins draining the testicle. A number of different theories can account for this phenomenon but since it usually results in the left side .Most feel it is a result of the geometry between the left testicular vein and the left renal vein 

2.) Varicocele can be bilateral though more common on the left due to left testicular /Gonodal vein being perpendicular to Left Renal vein. The left testicular vein enters the renal vein at a right angle compared to the right testicular vein which enters the IVC at a sharper angle . Thus creating more potential for backflow down the vein on the left side. Furthermore,the LT vein connects to the LR vein higher in the body than the RT vein enters the IVC meaning there is a greater column of fluid and pressure due to gravity on the left side .

3.) Another theory relates to the valves that veins in the body normally have in order to prevent backflow If the blood flows upward against gravity . It is felt by some that these valves in the testicular veins do not function properly allowing more blood to put back pressure on them . Most likely different mechanism combine their effect in different proportions in different people .

  Varicocele usually begin during adolescence between 10 - 19 years of age . Overall they affect about 15% of young adult males. Most varicoceles affect the left side but about 50% are bilateral meaning they are found on both the left and right sides.The finding of a varicocele on the right side only is extremely rare and requires careful investigation as these cases may be caused by a tumor or other blockages of veins in that side . These percentages maybe be an underestimate since varicocele usually cause no symptoms and are likely under-reported. 

Effects of varicocele.

 Varicocele can stunt the growth of the testicles and they can have an association with male fertility problems meaning they can impair normal sperm functions and interfere with the man's ability to father children . Approximately 50% of men diagnosed of male infertility have varicoceles compared to 15% in the general population .Most researchers believe that this is because varicoceles can damage the testicles due to over heating . Testicles normally are about 2° cooler than the rest of the body and this temperature different is essential for sperm production . A varicocele on one side can have effect on both testicles. Correcting or repairing varicoceles can improve semen quality , fertility and the growth of the testicles . Varicocele can also be an uncommon cause of pain in the testicles , because pain is such a complex process the source of it is difficult to localize in these situations repair of the varicoceles does not always relieve the perceived pain usually varicoceles are not associated with any symptoms in other words they go unnoticed when they become large enough they are detected as a painless scrotal mass classically described as a "bag of worms" . Men may discover them when they begin to perform self examination for testicular cancer often they are discovered by a routine examination by a doctor.

Diagnosis.

 In diagnosing a varicocele, your doctor will first perform a detailed medical interview followed by a physical examination . For a proper physical exam a warm room is needed the patient is examined either when standing or lying with and without abdominal straining this allows the doctor to grade the severity of the varicocele when present the doctor . If present the doctor will feel a painless compressible mass above the testicle well there are no special tests that can replace a good medical history and physical exam. A well done ultrasound in the standing position can sometimes confirm the diagnosis . Ultrasound involves passing a device called the transducer over the scrotum and examining it's contents using sound waves .

  The figure below shows how varicocele can be graded with it's severity

  

Grade 1: is a small mass that can be felt only present during a valsalva maneuver where a deep breath is taken and held and pushed downward to increase abdominal pressure .

Grade 2: is a moderate sized that can be felt without this straining maneuver .

Grade 3: is a large mass visible through the skin of the scrotal sac, because varicocele can stunt the growth developing testicles part of physical examination involves an assessment of the size and volume testicles while some doctors may gage this by experience it is most accurately done using a standard measuring device such as prader or disc orchidometer.

 Varicocele are very common and many men would never experience any adverse effects of them. For this reason , surgical correction is not always necessary. When varicoceles are found during adolescence surgical corrections should be considered if there is reduced testicular size on the side of the varicocele. The cut-off commonly used to determine the need for surgery is when there is a great than 20% reduction in testicular volume compared to the other side . In adults, surgery is most commonly considered as an option to improve fertility. In other words,if there is an otherwise unexplained fertility problem and semen abnormality in combination with a varicocele then surgery is recommended. Testicular pain which is describe as a dragging ache particularly in late in the day or after prolonged standing is a less common reason to treat with surgery in the absence of these preceding indications then observation is the best solution when treatment is required then one has several choices including ;

 1.) Open or laproscopic surgery ; where the dilated veins are tied off or a procedure performed by a radiologist percutaneous occlusion where the veins are blocked off with special material .

Treatment.

Most of the techniques used in treating varicocele have similar effectiveness and most are done as outpatient procedures meaning that no overnight hospital stay is required. The choice of technique will depend on it's 

. Availability.

. The surgeon's training and the specifics of the patients condition.

1.) Open surgery : This means that an incision or cut is made in the skin ,this is usually an out patient procedure and takes about 20 - 30 minutes . It is performed by a specialized surgeon called an urologist it is usually but not always done under general anesthesia meaning that you are put to sleep for it by a doctor called an anaesthesiologist . In some cases, doctors may prefer to do the procedure under local anaesthesia or freezing only or with spinal anaesthesia where you are frozen from the waist down with a needle in the back regardless of which procedure you will undergo ,the following recommendations are made ;

a.) Do not eat or drink anything for 12hours prior to surgery usually nothing after midnight the night before .

b.) Do not take any products containing aspirin or ASA for 5 days prior to surgery as this can increase the chance of bleeding afterwards and your doctor or hospital will instruct you in more detail if other precaution or preparation are required .

  In the case of an open varicocele repair the incision in the skin is very small usually about a 3cm or even less it is usually made in the lower part of the groin as shown below 

  

   

   After the incision is made the cord of structures containing the blood supply to the testicles the testicular artery,the dilated veins draining the testicles and the sperm duct called the vas deferens is isolated and exposed . The veins are carefully dissected away from the other structures then tied off and cut some surgeon's prefer to do this operation with the aid of a surgical microscope and this is called micro-surgery this provides magnification for the surgeon and improves his or her view of the tiny structures being operated on the proposed advantages of this technique are ;

. To reduce the chance of injury to the testicular artery, lymphatic vessels and the vas deferens.

. To improve the identification of all veins to reduce the chance of reoccurrence of the varicocele.

. To reduce the risk of a hydrocele which is a collection of watery fluid around the testicle after surgery

  

 Some surgeon's choose to perform a laparoscopic repair . Laparoscopic surgery involves performing an operation using special instruments passed into the body through tiny incisions in the skin .The procedure is visualized on a video monitor connected to a video telescope also passed in the body this way. It was initially thought that this type of surgery would allow for quicker recovery time following varicocele repair as it does for other operations . However,it proved unfortunately to be associated with higher risk of more severe rare complications it can also take longer than the traditional open surgery for these reasons laparoscopic varicocele repair is no longer offered in many centers.

Regardless of the type of surgery performed once the operation is completed the incision in the skin is closed together with tiny dissolvable stitches and the patient is transferred to a recovery area or day surgery unit . After a short period of observation, the patient is discharged home with a family member or friend . It is recommended to stay off work for 1week and to perform only light activities for 2weeks after the operation. Following surgery your doctor will outline your post operation care it is often recommended that you keep the wound dry for 24hours and avoid bathing for at least 48hrs if you experience discomfort after the procedure it is best to take an over the counter pain killer such as ;

. Acetaminophen ( Tylenol ™) ,or

. Ibuprofen ( Motrin™ , Advil™ )

  Your doctor may prescribe something stronger than this to use if necessary. It is normal following varicocele surgery to have mild discomfort in the scrotum or groin and some mild bruising or swelling of the skin ,a slight bit of blood from the wound is also within normal . In general the risk of complications following varicocele repair is quite low having said this it is a surgical procedure and complications can develop things to consider or watch for include;

. An infection and abscess under the skin which might occur in less than 1% of cases.

. A collection of blood or watery fluid in the scrotum called the hydrocele which occur in up to 3% of cases.

. Reoccurrence or persistence of varicocele which is reported to occur in about 7% of cases.

 With these in mind you should call your doctor or any health care provider if you develop any of the following symptoms;

. A high fever that persists.

. Drainage of pus through the incision or a large collection of fluid around the testicle.

  Unfortunately having a varicocele repair does not guarantee successful pregnancy or complete reduction in pain . For patients experiencing problems in fertility where the varicocele is felt to be a factor improvement on semen analysis are likely to be seen in 60% of cases following surgery this may translate to a pregnancy rate in the order of 40% although this is difficult to accurately determine from research studies. In adolescence testicular growth will usually be observed where the size of the affected testicle catches up to normal when done for pain unfortunately results are highly variable and one simply cannot guarantee successful resolution of pain. This is because the cause of pain is so difficult to diagnose and pin-point and the pain response is so complex that even when a varicocele is found in relation to pain in that area it is not necessarily the known cause of that pain .

3.) Percutaneous Occlusion : percutaneous means through the skin and usually refers to procedures formed by passing a needle into the body and performing a procedure using this point of access . A percutaneous occlusion of a varicocele involves passing s needle into a large vein in the leg guiding it X-ray up and around to the testicular vein then using special materials such as coils, balloons or other products to occlude or block off the testicular vein and varicocele . This procedure is performed by a specialized doctor called an intraventional Radiologist and is usually performed in the diagnostic imaging or X-ray department at the hospital or clinic . They usually require only local anaesthesia or freezing . Percutaneous occlusion has the disadvantage possibly taking longer than other techniques but the advantage of avoiding the need of general anesthetic it allows for quicker recovery . Success rate in this procedure depend largely on technical experience and the expertise of the center and the clinical situation. For example, the procedure can be more difficult in adolescents with small veins and in men with varicoceles on both sides . Overall slightly higher recurrence rates have been recorded compared to surgery in the order of 10% again however this would vary from center to center , technical problems limiting the ability to carry out the procedure have been reported in about 10% of cases . Percutaneous occlusion is generally a safe procedure however minor complications can rarely occur such as bleeding at the skin puncture site ,mild infection or inflammation ,fainting. A more serious but rare complication can occur if the occluding material migrates out of position and is carried elsewhere by the bloodstream.

Conclusion.

If you think you do have a varicocele do not worry as this is a common and for most men harmless condition if you are concerned about a fertility problem see your doctor who can confirm the diagnosis . Remember that 87% of men with a varicocele are fertile and are able to father children . If one of your testicles is significantly smaller than the other or if you have ongoing testicular pain see your doctor for evaluation also if you think you have a varicocele on the right side you should seek medical attention .

References; 

 Campbell's urology , 8th edition ; ed.: Walsh , P.C , Retik , A.B., Vaughan ,E.D . Wein, A.J.; pub.; Saunders (2002) 

Biyani ,C.S ., Cartledge., J.& Janestschek ,.G. (2005) Varicocele . Clin. Evid . 15:1-5