Varicocele

What Is a Varicocele?
Varicoceles are a relatively common condition (affecting approximately 10 percent of men) that tends to
occur in young men, usually during the second or third decade of life. Sometimes, these varicoceles cause
no symptoms and are harmless. But sometimes a varicocele causes pain or atrophy (shrinkage), or fertility
problems.
Normally, blood flows to the testicles through an artery, and flows out via a network of tiny veins that drain
into a long vein that goes up through the abdomen. The direction of blood flow in this vein should always
be up, toward the heart. A series of one-way valves in the vein prevent the reverse flow of blood back to
the testicles.

What Causes Varicoceles?

These one-way valves sometimes fail. The reverse flow of blood stretches and enlarges the tiny veins
around the testicle to cause a varicocele, a tangled network of blood vessels, or varicose veins (see Figure
1).

Varicocele Symptoms
Typical varicocele symptoms are mild and many do not require treatment. Treatment may be necessary if
the varicocele is causing discomfort or any of the other problems listed below.

Signs of Varicoceles
Pain
One of the signs of varicoceles is an aching pain when the individual has been standing or sitting for an
extended time and pressure builds up in the affected veins. Heavy lifting may make varicocele symptoms
worse and, in some cases, can even cause varicoceles to form. Usually (but not always) painful varicoceles
are prominent in size.

Fertility Problems
There is an association between varicoceles and infertility or subfertility, but it is difficult to be certain if a
varicocele is the cause of fertility problems in any one case. In one study, as many as 40 percent of men
who were subfertile were found to have a varicocele. Other signs of varicoceles can be a decreased sperm
count; decreased motility, or movement, of sperm; and an increase in the number of deformed sperm. It is
not known for sure how varicoceles contribute to these problems, but a common theory is that the condition
raises the temperature of the testicles and affects sperm production. Studies have shown that from 50
percent to 70 percent of men with fertility problems will have a significant improvement in the quality
and/or quantity of sperm production after they have undergone varicocele repair.

Testicular Atrophy
Atrophy, or shrinking, of the testicles is another of the signs of varicoceles. The condition is often diagnosed
in adolescent boys during a sports physical exam. When the affected testicle is smaller than the other,
repair of the variocele is often recommended. The repaired testicle will return to normal size in many cases.

Diagnosis
Sometimes a varicocele can be diagnosed during a physical examination. A large varicocele may make the
scrotum look lumpy so it resembles "a bag of worms" (see Figure 2).
When varicocele symptoms are not clearly present, the abnormal flow of blood can often be detected with a
noninvasive imaging exam called color flow ultrasound. Varicoceles also may be detected with a venogram an x-ray in which a special dye is injected into the veins to "highlight" blood vessel abnormalities.

A color flow ultrasound image of a prominent varicocele

Treatment Options
In the United States, varicocele treatment has traditionally involved open surgery, usually
performed by a urologic surgeon, or urologist. In recent years, however, a safe and effective
nonsurgical alternative called varicocele embolization is becoming the treatment of choice for
many patients and their physicians.

Varicocele Surgery
Varicocele Surgery is usually performed under general anesthesia in an outpatient setting.
Occasionally, the surgery is performed with a local anesthetic.
In this type of varicocele treatment, the surgeon makes an incision above the scrotum (or higher
in the flank area) and cuts through the layers of tissue to expose the veins (see Figure 3).

All Varicocele Pictures on this site copyright John Yesko, 2001

The affected veins are ligated, or tied off, to detour the flow of blood into normal veins.
Sometimes a laparoscope (a cylindrical metal scope inserted into the abdomen) is used to
perform the surgery. Recovery time depends on the type of surgery, but most patients require up
to six weeks before heavy lifting and other strenuous activities can be performed. Light activities
may be resumed more quickly.

Varicocele Embolization
Varicocele embolization is an outpatient procedure that is performed without general anesthesia
using "twilight" sedation. In this type of varicocele treatment, a small tube is inserted into the groin
through a small nick in the skin (about the size of the lead in a pencil). Sometimes the tube is put
in through a vein in the right side of the neck. The skin is numbed for this procedure and it is not
painful. Next, a small catheter, or tube, is painlessly guided up into the abdomen and into the
varicocele vein under the guidance of x-ray imaging (see Figure 4).

All Varicocele Pictures on this site copyright John Yesko, 2001

A dye is injected to create an x-ray map (venogram) of the vein and tiny metal coils or other
embolizing substances are inserted through the catheter to block the flow of blood to the vein
(see Figure 5).
The tube is removed and no stitches are needed. Patients are observed for a few hours and go home the
same day. Recovery from varicocele embolization typically takes less than 24 hours and patients often
return to work the next day.

Advantages of Varicocele Embolization

The majority of men in the United States undergo surgery as varicocele treatment. This
is because they are usually sent to surgeons for evaluation, and many do not know
about varicocele embolization.
The advantages of this alternative, interventional radiology varicocele treatment
include:

It is as effective as surgery, as measured by improvement in pain, semen

analysis and pregnancy rates.
It does not require any surgical incision in the scrotal area.
A patient with varicoceles on both sides can have both fixed at the same time
through one vein puncture site (surgery requires two separate open incisions)
General anesthesia is not used for embolization (most surgery is done under
general).
There is a lower rate of complications compared to surgery. Infection has
not been reported after embolization.
It requires less recovery time. Post embolization patients are virtually never
admitted to the hospital (in one study 24% of surgical patients needed hospital
admissions, but no embolization patient did). Even patients with physically
demanding jobs may return to work within the next day or two, unlike post
surgical patients.

Fig.1 The photograph shows bilateral variations in the renal and testicular
veins.
1. Right additional renal vein (RARV) draining directly into IVC
2. Right additional renal vein (RARV) receiving rieght testicular
vein (RTV)
3. Formation of left renal veing (LRV)
4. Left testicular veing (LTV) draining into lower tributary of left
renal veing (LLRV)

Varicocele
Definition
A varicocele is an enlargement of the veins within the scrotum, the loose bag
of skin that holds your testicles. A varicocele is similar to a varicose vein that
can occur in your leg.
About one in six men have a varicocele. For males who are infertile, the
figure is higher about 40 percent. Varicoceles are the most common cause
of low sperm production and decreased sperm quality, although not all
varicoceles affect sperm production.
Most varicoceles develop over time. Fortunately, most varicoceles are easy to
diagnose and, if they cause symptoms, can be repaired surgically.

Symptoms
A varicocele often produces no symptoms. Rarely, it may cause pain that
may worsen over the course of a day because of physical exertion and
typically is relieved by lying down on your back. With time, varicoceles may
grow larger and become more noticeable.

Causes
The spermatic cord, which supplies blood to and returns blood from the testicle, houses
the vas deferens, which carries sperm from the testicles. The pampiniform plexus is a
group of veins within the scrotum and above the testicles. The pampiniform plexus drains
blood from the testicles. Enlargement of these veins often occurs during puberty.
It's not certain what causes varicoceles, but many experts believe abnormal
valves within the veins prevent normal blood flow. The resulting backup
causes the veins to widen (dilate).
Varicoceles usually occur in the region of the left testicle, most likely because
of the position of the left testicular vein. However, a varicocele in one testicle
can affect sperm production in both testicles.

Male reproductive system

The vas deferens, situated within the spermatic cord, carries sperm from the testicles.

Varicocele

A varicocele occurs when faulty valves develop in the veins along the
spermatic cord in the scrotum.

Risk factors
You're at greater risk of varicoceles between the ages of 15 and 25.

When to seek medical advice

Because of the lack of symptoms, a varicocele often is discovered during an
evaluation of fertility or during a routine physical exam.
However, if you experience pain or swelling in your scrotum, contact your
doctor. A number of conditions can cause testicular pain, and some of the
conditions require immediate treatment. Your doctor can determine which
condition is causing your pain.

Tests and diagnosis

Your doctor will conduct a physical exam, which may reveal a twisted,
nontender mass above your testicle. Some people have described the mass
as feeling like a bag of worms. If it's large enough, your doctor will be able to
feel it while you're standing up. If you have a smaller varicocele, your doctor
may ask you to take a deep breath and hold it while you bear down (Valsalva
maneuver). This helps your doctor detect abnormal enlargement of the
veins.
If the physical exam is inconclusive, your doctor may order a scrotal
ultrasound. This test, which uses high-frequency sound waves to create
precise images of structures inside your body, may be used to ensure there
isn't another reason for your symptoms. One such condition is a tumor that
compresses the spermatic vein.

Complications
A varicocele may cause:

Shrinkage of the affected testicle (atrophy). The bulk of the

testicle is made up of sperm-producing tubules. When damaged, as
from varicocele, the testicle shrinks and softens. It's not clear what
causes the testicle to shrink, but the malfunctioning valves allow blood
to pool in the veins, which can result in increased pressure in the veins
and exposure to toxins in the blood that may cause testicular damage.
Infertility. It's not clear how varicoceles affect fertility. Some experts
believe the testicular veins cool blood in the testicular artery, helping

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to maintain the proper temperature for optimal sperm production. By

blocking blood flow, a varicocele may keep the temperature too high,
affecting sperm formation and movement (motility).

Treatments and drugs

Varicocele treatment may not be necessary. However, if you're infertile or
your varicocele causes pain or testicular atrophy, you may want to undergo
varicocele repair. Treatment is aimed at sealing off the affected vein to
redirect the blood flow into normal veins.
Although varicoceles typically develop in adolescence, it's less clear whether
you should have varicocele repair at that time. Indications for repairing a
varicocele in adolescence include progressive testicular atrophy, pain or
abnormal semen analysis results.
Varicocele repair presents relatively few risks. Increased fluid around the
testicles (hydrocele) occurs in a small percentage of cases. Recurrence of
varicoceles is a risk, affecting perhaps one in 10 men who undergo repair.
Repair methods include:

Open surgery. This most common form of treatment usually is

done on an outpatient basis, using general or local anesthetic. Your
surgeon may approach the vein through your groin (transinguinal),
abdomen (retroperitoneal) or below your groin
(infrainguinal/infrapubic). Transinguinal surgery is most frequently
used.
Recovery after surgical repair usually proceeds rapidly. Your doctor
may advise you to return to normal activities that aren't strenuous
after two days. As long as you're not uncomfortable, you may return
to more strenuous normal activity, such as exercising, after two
weeks. Pain resulting from this surgery is generally mild. Your doctor
may prescribe pain medication for the first two days after surgery.
After that, your doctor may advise you to take over-the-counter (OTC)
painkillers, such as acetaminophen (Tylenol, others) or ibuprofen
(Motrin, Advil, others) to relieve discomfort.
Your doctor may advise you not to have sexual intercourse for one
week. It takes about 72 days for sperm to generate, so you'll have to
wait three or four months after surgery to get a semen analysis to
determine whether the varicocele repair was successful in restoring
your fertility.

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Laparoscopic surgery. With this approach, your surgeon makes a

small incision in your abdomen and passes a tiny instrument through
the incision to see and to repair the varicocele. However, this
procedure, which requires general anesthetic, isn't used commonly
because it poses more risk while offering little advantage.
Percutaneous embolization. A radiologist inserts a tube into a
vein in your groin or neck through which instruments can be passed.
Viewing your enlarged veins on a monitor, the doctor releases coils or
balloons to create a blockage in the testicular veins, which interrupts
the blood flow and repairs the varicocele. This procedure uses sedation
and may take several hours. Again, because of presenting greater
risks than open surgery and offering little advantage, this procedure
isn't widely used.

http://www.maleinfertility.org/new-varicocele.html
http://medind.nic.in/jae/t06/i2/jaet06i2p69.pdf
http://anatomy.uams.edu/AnatomyHTML/veins_pelvis&perineum.html

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