What are varicoceles?
The purpose of veins within the human body is to transport blood from an organ back to the heart and lungs. The veins that drain the testicles are unique and for a plexus of interconnected veins that travel within the spermatic cord. This plexus of veins has an important role in maintaining testicular temperature 2 to 4 degrees cooler than core body temperature. This “cooling effect” is essential for optimizing sperm production.
Varicoceles are abnormally engorged testicular veins that allow retrograde flow, whereby blood actually moves toward the testicles rather than toward the heart. As a result, the “cooling effect” is lost, and the testes may experience a different hormonal or biochemical environment. Varicoceles can lead to growth retardation of the testes and can cause poor sperm production and quality. The biggest semen analysis parameter impacted by varicocele appears to be motility.
Varicoceles are common and are present in nearly 15 percent of men in the general population. Approximately 35 to 40 percent of men evaluated for infertility are found to have a varicocele, and it is thought to be one of the most common reversible causes of male factor infertility.
Most men with a varicocele to not have any symptoms. Rarely, varicoceles cause testicular pain. When present, the pain is generally dull and achy in nature and is worsened by vigorous activity or long periods of sitting or standing. Pain is often relieved with lying supine and therefore almost never awakens a man from sleep.
Varicoceles are usually identified through self-exam or during routine physical exam by a healthcare provider. They may look or feel like a mass or bulge in the scrotum. During an exam by a physician, you may be asked to hold a deep breath, and bear down while the physician feels the scrotum above the testicle. This pressurizes the veins and allows their identification. In some instances, a physician may have a patient undergo scrotal ultrasound to better characterize the varicocele and the testicles. Routine radiographic screening for varicoceles in the absence of physical findings is not indicated.
Patients should consider treatment of varicoceles if they are experiencing infertility, pain or testicular atrophy. There are no medications that will treat or prevent varicoceles.
There are two approaches to the treatment of a varicocele:
Surgical varicocelectomy: This approach allows ligation (obstruction) of the testicular veins to stop the retrograde blood flow. The surgery is minimally invasive and requires a small (< 1 inch) incision just below the pubic hair line. An operating microscope is used to identify the abnormal veins as they course through the spermatic cord. Intraoperative ultrasound is used to identify and preserve the testicular artery. The operation can typically be performed in under one hour and recovery is brisk with most men returning to work within one to two days.
Percutaneous Embolization: This procedure is performed by radiologists who will insert a catheter into a vein in the groin or neck. Using x-rays and contrast dye, the abnormal testicular veins are identified and blocked by releasing coils or balloons within the veins. This approach has a higher rate of recurrence than surgery. This is the most frequent technique employed in cases of varicocele recurrence after surgery.