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.
What Causes Varicoceles?
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.
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 varicocele 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
| Click to see an animation of the varicocele embolization procedure. |
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).
 All Varicocele Pictures on this site copyright John Yesko, 2001 |
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.