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A varicocele is a scrotal abnormality defined by elongated, dilated and tortuous veins that drain the testicle (Figure 1). Varicoceles are common, observed in 15% of the general male population, and are presumably an evolutionary consequence of men’s upright posture. Most varicoceles (>80%) occur on the left side and the remainder on both sides. They are generally acquired during puberty.
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Several theories have been proposed to explain their occurrence, including poorly functioning valves and increased resistance to blood flow where the varicocele veins drain, creating a “dam-like” effect and increasing venous pressure. They do not cause cancer and are not life threatening, but are simply an anatomic consequence of being human. To learn more about varicoceles and treatment options, including surgery, please select one of the following topics. If you are ready to schedule a consultation, please request a consultation here.
Non-Surgical Fertility Treatment for Males and Causes of Infertility Surgical Male Fertility Treatment Sperm Mapping Sperm Retrieval Experiencing Pain? Varicocelectomy Symptoms, Treatment, Repair and Surgery for Varicoceles Ejaculatory Duct Obstruction and Resection Vasectomy Procedures Vasectomy Reversals
Most varicoceles are asymptomatic. However, they can be uncomfortable and cause scrotal pain. This pain is generally mild to moderate, occurs with long periods of sitting, standing or activity and is relieved by lying down. Although it can be uncomfortable before bedtime (after a long day of activity), it generally does not occur upon awakening after a night’s rest. The pain is dull, congestive‚ “tooth ache” like and generally doesn’t refer elsewhere. It is not associated with urination issues or erectile dysfunction; however, it is associated with male infertility. Lastly, when large, a varicocele can cause a clumpy “bag of worms” feel in the scrotum and can be bothersome for this reason as well.
FIGURE 1. Varicocele (V) is the blue set of veins that drain blood from the testis to the body.
Approximately 35% of men in Dr. Turek’s practice who are evaluated for infertility will have a varicocele, a much higher rate than that found in the general population (15%). Over the last 50 years, this had led to the intensive study of the relationship between varicoceles and male infertility. The mechanism by which a varicocele on one side can affect the fertility of both testicles is not clearly understood. What is true is that the temperature of the scrotum is normally several degrees cooler than body temperature, which is important for normal sperm production and testis function. This temperature difference is carefully maintained by the normal anatomy of the scrotum. The dilated veins in a varicocele may decrease the effectiveness of this natural cooling mechanism and “overheat” the testis and reduce its ability to function. Exactly how heat affects sperm production is currently the subject of much male fertility research. However, a leading theory suggests that increased oxidative stress reduces the fertility of varicocele patients. In addition, there is recent data that shows that sperm DNA fragmentation rates, a measure of sperm quality, can be elevated in men with varicoceles and that varicocele repair can significantly lower these rates. In any case, the semen analysis in varicocele patients can show impaired sperm numbers, movement or both.
The “gold standard” way to diagnose varicoceles is by physical examination. With a patient in a standing position, palpation of the scrotum by a well-trained physician can reveal a varicocele. Exercise and prolonged standing may also demonstrate a varicocele. Difficulties palpating a varicocele arise when the scrotal wall is thick or contracted. In addition, benign fat, termed lipoma of the cord, can feel like a variocele. Unlike a varicocele, however, a lipoma will not go away when the patient lies down.
A grade III varicocele seen as bulges under the skin above the patient’s left testicle.
Read about Varicocele Treatment Patient Instructions Table 1. Varicocele size and grading Subclinical
Varicocele Not Detected Upon Physical Exam; Found By Radiologic or Other Imaging Study
Grade I
Varicocele only palpable during or after Valsalva maneuver on physical exam.
Grade II
Varicocele palpable on routine physical exam without the need for Valsalva maneuver.
Grade III
Varicocele visible to the eye and palpable on physical exam.
Varicoceles have been arbitrarily divided into 3 grades based upon physical examination findings (Table 1). Subclinical varicoceles are lesions not detected by routine examination, but are suggested by radiologic or other imaging methods. These lesions are smaller than “clinical” varicoceles and, in Dr. Turek’s view, the value of varicocele repair of these lesions is unknown. Grades I-III are considered “clinical” varicoceles, as they are found on physical examination alone. It is these lesions that are repaired for issues of discomfort or infertility. The diagnosis of varicocele can also be made with venography, ultrasound, thermography, scintigraphy and CAT scan or magnetic resonance imaging. Venography is considered to be the best diagnostic test, but it is invasive, involving catheterization of large leg veins to access this system. Conveniently, venography can be combined with embolization using balloons or coils to treat varicoceles at the same time. Doppler ultrasound is less invasive than, and correlates well with, venography and relies on the detection of venous flow within the varicocele. This is the test that Dr. Turek prefers to have patients do if there is a question about whether or not a patient has varicoceles. Thermography, scintography and MRI or CAT scans are of limited clinical use for varicocele mostly because of increased cost, and lack of controlled studies surrounding their use.
The reasons to fix a varicocele include: An adolescent with a large varicocele and evidence of a smaller testis on the side of the varicocele. For varicocele-induced scrotal pain For correction of male factor infertility To raise mildly low testosterone levels
The goal of varicocele treatment is to stop the backward flow of blood from the body to the scrotum, and therefore to “cool off” the testicles. To achieve this, veins leading from the testis to the body are tied off or interrupted as completely as possible. A single vein is left open (vasal vein) that is not subject to the same issues as the varicose veins and allows the blood to leave the testicle after surgery. There are several ways to treat varicoceles. Surgical or incisional methods are performed in the upper scrotum (subinguinal), groin area (inguinal) or lower abdomen (retroperitoneal). The procedure can also be performed with “telescope” surgery (laparoscopy) and also by an interventional radiologist through a procedure called venography and embolization (Table 2). Table 2. Varicocele treatments: Comparison of outcomes. Outcome Parameter
Incisional
Laparoscopic
Radiologic
Semen Improvement
66%
50-70%
60%
Pregnancy Rate
35%
12-32%
10-50%
Recurrence
0-5%
10-25%
10%
Technical Failure
Negligible
Small
10-20%
Cost
X
2X
X
Pain pills (average)
3-6
3-6
0-3
Days to Work
3
3
1
From: Zenke U and Turek PJ. Varicocele and Infertility. In: Office Andrology. Contemporary Endocrinology. Edited by Patton and Battaglia. Humana Press, Totowa NJ. 2005, pp.159-168. In general, all approaches give similar results; their differences stem mainly from other issues. For example, the incisional approach has the lowest recurrence rate, because it is performed in the groin or scrotum, where all of the venous “action” is taking place. With the radiologic approach, there is a significant “technical” failure rate as it is sometimes difficult to manipulate catheters through the necessary veins to reach and interrupt the veins of interest. This is especially true for varicoceles on both sides. With laparoscopy, again the varicocele recurrence rate after the procedure is high, because all of the venous “action” occurs in the scrotum and laparoscopy is performed in the abdomen.
For the past 15 years, Dr. Turek’s preference has been to perform the microscopic subinguinal approach to varicocele repair. The procedure begins with a 2-3 cm skin incision near the junction of the groin and upper scrotum. The spermatic cord is exposed and inspected on either side for external cremasteric veins. If present, these veins are tied off with silk suture. The marked incision site for subinguinal varicocelectomy.
The area around the testis is then inspected for the presence of any exiting veins and these are tied. The operating microscope is brought into the field and the investing layers of the spermatic cord opened. Microsurgical dissection of the cord is then performed: the artery is visually identified by its pulsations (with the help of a small doppler ultrasound if necessary) and all surrounding veins are tied. Lymphatic vessels are noted and spared to prevent hydrocele formation. At the end, only the vasal veins remain intact to provide venous return from the testis.
Veins within the spermatic cord have been tied off microsurgically.
The spermatic cord is then returned to its bed and the incision closed in two layers. Steri-strips and a bandage are placed. The patient receives pain pills and is advised to return to work as soon as 3 days after the procedure. It is best to return to work without the need to take narcotic pain pills, as they may cloud judgment. The patient is seen in the office 1-2 weeks later for a quick checkup and then formally assessed for pain or infertility at 3-4 months after the procedure. Read Varicocele Patient Instructions, Preparing for Varicocele Repair Surgery.
Complication rates must also be considered in any decision to have varicoceles treated. The overall complication rates range from 1% for the incisional approach to 4% for laparoscopy and 10% for radiologic methods (including technical failures) (see Table 3). The most significant complication with radiologic occlusion is the chance that the culprit veins cannot be accessed or interrupted (technical failure rate). Although the list of potential complications is long, remember that the chance of having a complication is really quite low. Table 3. Varicocele complications: A comparison of methods. Treatment
Potential Complications Anesthetic
Intraoperative
Postoperative Hematoma, Testis atrophy, Hydrocele, Reccurence
Incisional Repair (Operative