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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.

Varicoceles are a common cause of low sperm production and decreased sperm quality, which can cause infertility. However, not all varicoceles affect sperm production. Varicoceles can also cause testicles to shrink.

Most varicoceles develop over time. Fortunately, most varicoceles are easy to diagnose and many don't need treatment. If a varicocele causes symptoms, it often can be repaired surgically.


Symptoms

A varicocele often produces no signs or symptoms. Rarely, it may cause pain. The pain may:
  • Vary from dull discomfort — a feeling of heaviness — to sharp
  • Increase with sitting, standing or physical exertion, especially over long periods
  • Worsen over the course of a day
  • Be relieved when you lie on your back

With time, varicoceles may enlarge and become more noticeable.

When to see a doctor

Because a varicocele usually causes no symptoms, it often requires no treatment. Varicoceles may be discovered during a fertility evaluation or a routine physical exam.

However, if you experience pain or swelling in your scrotum or you discover a mass on your scrotum, contact your doctor. A number of conditions can cause a scrotal mass or testicular pain, some of which require immediate treatment.

Causes
Your spermatic cord carries blood to and from your testicles. It's not certain what causes varicoceles, but many experts believe a varicocele forms when the valves inside the veins in the cord prevent your blood from flowing properly. The resulting backup causes the veins to widen (dilate).

Varicoceles often form during puberty. Varicoceles usually occur on the left side, most likely because of the position of the left testicular vein. However, a varicocele in one testicle can affect sperm production in both testicles.

Complications
  • Shrinkage of the affected testicle (atrophy). The bulk of the testicle comprises 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. The testicular veins cool blood in the testicular artery, helping to maintain the proper temperature for optimal sperm production. By blocking blood flow, a varicocele may keep the local temperature too high, affecting sperm formation and movement (motility).

Tests and diagnosis
Your doctor will conduct a physical exam, which may reveal a twisted, nontender mass above your testicle that may feel like what's been described as a bag of worms. If it's large enough, your doctor will be able to feel it. If you have a smaller varicocele, your doctor may ask you to stand, 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.

Treatments
Varicocele treatment may not be necessary. However, if your varicocele causes pain, testicular atrophy or infertility, you may want to undergo varicocele repair. The purpose of surgery is to seal off the affected vein to redirect the blood flow into normal veins. However, the effect of varicocele repair on fertility is unclear.

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, which may include:
  • Buildup of fluid around the testicles (hydrocele)
  • Recurrence of varicoceles
  • Damage to an artery

Repair methods include:
  • Open surgery. This treatment usually is done on an outpatient basis, using general anesthetic or local anesthetic. Commonly, your surgeon will approach the vein through your groin (transinguinal), but it's also possible to make an incision in your abdomen or below your groin.
Advances in varicocele repair have led to a reduction of post-surgical complications. One advance is the use of the surgical microscope, which enables the surgeon to see the treatment area better during surgery. Another is the use of Doppler ultrasound, which helps guide the procedure.

You may be able to return to normal, nonstrenous activities after two days. As long as you're not uncomfortable, you may return to more strenuous activity, such as exercising, after two weeks.

Pain from this surgery generally is 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 (Advil, Motrin, others) to relieve discomfort.

Your doctor may advise you not to have sex for one to two weeks. 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.
  • Laparoscopic surgery. Your surgeon makes a small incision in your abdomen and passes a tiny instrument through the incision to see and to repair the varicocele. This procedure requires general anesthesia.
  • 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 a solution that causes scarring to create a blockage in the testicular veins, which interrupts the blood flow and repairs the varicocele. This procedure is done with local anesthesia on an outpatient basis. This procedure isn't as widely used as surgery.

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