Varicocele

Overview

Veins in the body transport blood from various organs back to the heart. They usually feature valves that guarantee the blood flows in the right direction. When the valves in the testicular vein do not function correctly, gravity causes blood to pool in the scrotum, resulting in a varicocele. They often occur on the left side, and are most likely connected to the path of the testicular vein in the abdomen.

What is Varicocele?

A varicocele is a condition in which the scrotal venous pampiniform plexus, which drains blood from each testicle, dilates and enlarges abnormally. Varicoceles are clinically relevant because they are the most often discovered cause of aberrant sperm analysis, low sperm count, impaired sperm motility, and poor sperm morphology.

Varicoceles affect around 15% to 20% of all males, but approximately 40% of infertile individuals. Although various ideas exist, it is unknown how a varicocele affects sperm production, structure, and function. The link between clinically severe varicoceles and male infertility, on the other hand, is unequivocal. This link was discovered by Barfield, a British physician, in the late 1800s and verified by others in the early 1900s.

Varicoceles are categorized into three sizes depending on their clinical appearance and visible size.

What Happens Normally?

The male reproductive system produces, stores, and transports sperm. The scrotum is the skin pouch that houses the testicles (testes). The testicles produce sperm as well as the hormone testosterone. Sperm matures as it travels through a coiled tube behind each testicle (the epididymis)

The vas deferens tube transports sperm from each epididymis to the prostate. Seminal fluid in the prostate combines with sperm to make semen when you ejaculate. The sperm passes via the urethra and exits through the tip of your penis.

The spermatic cord contains the vas deferens and the testicular artery, which transports blood to the testis. It also contains the pampiniform plexus, a collection of veins that drain blood from the testicles. For optimal sperm generation, development, and function, the testes require a body temperature that is lower than our core body temperature. The scrotum has a five-degree lower body temperature than the belly or pelvis.

The latter is attributed to the existence of the pampiniform plexus, which acts as a heat exchanger in the testicular artery, chilling blood before it enters the testicles. This keeps it at the physiological temperature required to produce high-quality sperm. Overheating of the testes can impair sperm production and function, resulting in a diminished reproductive potential when these veins grow swollen, as in varicocele. 

Are Varicoceles Common?

Varicoceles affect around 15 out of every 100 males. It's difficult to determine which of these 15 may experience reproductive issues as a result of their varicocele. However, about 4 out of every 10 men screened for reproductive issues had a varicocele and reduced sperm motility. There is no relation to other defects, race, birthplace, or ethnic background. Though varicoceles are frequently identified in men who are evaluated for infertility, 8 out of 10 men with varicoceles do not have reproductive issues.

Varicoceles Causes

The exact etiology of varicoceles is unknown, however it is considered to be caused by a blockage of venous blood flow in the internal spermatic vein, resulting in clinically evident venous engorgement on scrotal examination. Varicoceles are significantly more prevalent in the left testicle (80% to 90%). If a left varicocele is found, there is a 30% to 40% chance that it is a bilateral disease.

There are three theories as to the anatomical cause:

1. The "Nutcracker" effect occurs when the left internal spermatic vein gets caught between the superior mesenteric artery and the aorta. This entrapment causes venous compression and spermatic vein obstruction.
2. Failure of the anti-reflux valve where the internal spermatic vein joins the left renal vein. This failure causes reflux and retrograde flow in the testicular vein.
3. Angulation at the juncture of the left internal spermatic vein and the left renal vein.

Deep vein thrombosis, renal arteriovenous malformations, and thrombosis of the pampiniform plexus are all uncommon causes of varicoceles. Tobacco use and mutations in the glutathione S-transferase Mu 1 gene enhance the risk of male infertility. These variables may also raise the likelihood of developing a varicocele.

When a varicocele leads to an aberrant semen analysis, a "stress pattern" appears on microscopic semen testing. A low sperm count, poor motility, and a rise in the percentage of defective sperm characterize this pattern.

How does varicocele occurs? 

Infertility is usually the biggest worry with a varicocele. Many men with varicoceles are fertile, but their sperm is impaired in function, shape, quantity, or motility. Excess heat caused by increased oxidative stress on the sperm from blood pooling causing reduced oxygenation, direct hydrostatic pressure injury effects on the testis, toxin formation, hypoxia, autoimmunity, or an increase in adrenal steroids concentration being delivered to the testicle because the adrenal veins empty into the left renal vein almost directly opposite the entry of the internal spermatic vein The most widely recognized explanation holds that increased blood flow causes greater intratesticular temperatures, which are the primary cause of sperm impairment in varicoceles.

While untreated varicoceles might grow, they seldom, if ever, cause discomfort. Increased testicular temperatures, higher venous pressure, oxidative stress, hormonal imbalances, reflux of toxic metabolites from the kidneys or adrenals, hypoxia, or possible stretching of nerve fibers in the spermatic cords from the dilated varicocele complex are all proposed mechanisms for such pain. Orchialgia caused by varicoceles is commonly described as aching, dull, or throbbing, but it can also be severe, sharp, or stabbing.

Large varicoceles are expected to eventually induce testicular failure, leading in reduced hormone production, oligospermia, and testicular atrophy. Varicoceles can also affect the integrity of sperm nuclear DNA, which has been associated to decreased sperm motility, viability, numbers, and abnormal morphology.

Varicoceles can reduce testosterone synthesis by the testicular Leydig cells. Varicocelectomy improves blood testosterone levels in more than 80% of patients, with a mean rise of 100 to 140 ng/mL. Hypogonadal (testosterone 300 ng/mL) males had the largest rise in testosterone. This data shows that varicocelectomy might be a viable surgical option for treating low testosterone levels in hypogonadal males with large varicoceles in the long term.

Symptoms of Varicoceles

Asymptomatic varicoceles are common. If the varicocele is large enough, the patient may describe it as a "bag of worms." Varicoceles commonly appear as soft lumps above the testicle on the left side of the scrotum. Right-sided and bilateral varicoceles are possible. Patients may occasionally complain of scrotal discomfort or heaviness. They are frequently discovered during an infertility workup.

Large varicoceles are easily identifiable by basic examination and have the characteristic "bag of worms" look. Medium varicoceles are ones that may be identified by palpation or physical examination without the patient bending down. Small varicoceles are ones that can only be discovered through a powerful Valsalva maneuver (bearing down).

Diagnosis

Varicoceles are discovered through a standard doctor's visit or by self-examination of the scrotum. Because of the way they appear and feel, they've been dubbed a "bag of worms."

Urologists frequently examine patients while they are standing to look for varicoceles. Take a deep breath, hold it, and bear down when your urologist touches the scrotum above the testicle. The "Valsalva maneuver" is the name given to this procedure. It allows your urologist to detect any swollen veins.

A scrotal ultrasound test may be ordered by your urologist. Ultrasound creates an image of what's within your body by using sound waves. On ultrasonography, varicoceles are veins that are wider than 3 millimeters in diameter and have blood flowing in the incorrect direction during the Valsalva maneuver. The size of the testicles can also be determined via ultrasonography. These are helpful in determining how to treat teenagers. If no issues are felt during the physical exam, an ultrasound is not required.

There are no medical therapies that are successful. Analgesics and scrotal support can be utilized to relieve pain and discomfort caused by a varicocele. When a varicocele is surgically treated, it is generally done as an outpatient surgery. Retroperitoneal abdominal laparoscopic, infra-inguinal, sub-inguinal below the groin, and intrascrotal techniques are the most prevalent. Regardless the method, the vas deferens and testicular artery must be avoided during surgery.

Percutaneous embolization is another option, generally performed by interventional radiology. A catheter is passed from the femoral vein up the vena cava, laterally into the left renal vein, and finally inferiorly into the spermatic vein. This approach has been claimed to have an 89 % success rate.

Microsurgical procedures enable the detection of minuscule anastomosing vessels that would otherwise go undetected. It also allows for better identification of the testicular artery, reducing the risk of unintended harm to it.

Some pediatric urologists prefer a retroperitoneal, laparoscopic method that allows them to manage the spermatic vein very close to its entry into the left renal vein. This procedure, however, has a somewhat high recurrence rate (15 %).

Hematoma, hydrocele, infection, scrotal tissue damage, and vascular injury to the testis can all result in testicle loss.

In the literature, it is unclear which of the surgeries promotes male fertility the most. Microsurgical testicular sperm extraction and intracytoplasmic sperm injection(ICSI) may help couples who are infertile due to nonobstructive azoospermia and a varicocele 

The reasons for removing a varicocele include pain alleviation, reduced testicular shrinkage, and infertility. Candidates for repair must fulfill the following criteria:

• Infertility in males, normal fertility in females (although female infertility factors are not a contraindication for varicocele surgery in the male)
• Palpable varicocele
• Abnormal semen parameters ("stress pattern")
• Pain related to the varicocele
• In adolescents when associated with failure of testicular development and growth

If bilateral varicoceles are discovered, both are fixed at the same time. There is evidence that correcting both may be useful in inducing a pregnancy if there is a clinically substantial left varicocele but just a subclinical right varicocele.

Following surgery, around 70% had better sperm parameters, and 40% to 60% had increased conception rates. This enhancement in sperm quality is usually visible 3 to 4 months following surgery and becomes permanent by 6 months.

According to meta-analyses, the anticipated improvement in sperm count with varicocele surgery is 9.71 to 12.32 10 ml, while motility improves 10.86 percent and morphology improves 9.69 %. The majority of doctors do not advocate infertility surgery for subclinical varicoceles since it does not generally impair fertility or sperm parameters.

The cremasteric veins and the deferential vein provide alternate venous outflow from the testicle. Recently, intraoperative indocyanine green angiography was found to aid in the identification of the testicular artery during microsurgical dissection for varicoceles. During the process, the indocyanine green dye is administered intravenously. This enables arterial arteries to glow infrared, making it easier to identify them and reducing unintended artery damage. 

After Treatment

Healing time following surgery is short, and discomfort is usually minimal. You should refrain from exercising for 10 to 14 days. You may usually go back to work 5 to 7 days following surgery. You will also meet with your urologist. Semen analysis is performed three to four months after surgery for reproductive concerns.

Healing time following embolization is likewise quite brief, with just minor discomfort. Exercise should be avoided for 7 to 10 days following the surgery. One to two days later, you may usually return to work. The recurrence rate with embolization is comparable to that of surgery. However, in some circumstances, embolization is preferable than surgery.

The effect of varicocele repair on fertility is unknown. Some studies indicate that fertility improves following varicocele repair, whereas others do not. After varicocele treatment, approximately 6 out of 10 infertile men had improved sperm quality. This therapy should be considered with other reproductive treatment options.

Catch-up growth may or may not occur in teenagers whose primary cause for surgery is sluggish testicular development.

Complications

In some cases, a varicocele can lead to complications.

• Infertility

The most significant problem that can arise is infertility. It is most likely caused by the increased volume of blood in the area, which elevates the warmth of the testicles.

Varicoceles affect between 35 and 44 % of males suffering from primary infertility. Primary infertility occurs when a couple is unable to conceive after 12 months of trying. Varicoceles impact 45–81 percent of males suffering from secondary infertility. When a couple was able to conceive at least once but is no longer able to do so.

• Testicle shrinkage

Testicular atrophy, or shrinking, can result from a varicocele. The majority of the testicle is made up of sperm-producing tubules. If they are injured, the testicle may shrink and become softer.

• Hormone imbalances

A shift in hormones may occur when the cells react to the rise in pressure. There might be an increase in luteinizing hormone levels (LH). This hormone is found in both males and women, however it is more prevalent in women. There may also be normal-to-low testosterone levels.

Frequently Asked Questions

• What will happen if I choose not to be treated?

The vast majority of men with varicocele will have no issues. One in every five men with varicocele will have problems fathering children. After the age of 16, a sperm study is highly suggested to assess if varicocele correction is required. If a sperm analysis is normal, it is advised that it be repeated every 2 to 3 years since the quality of sperms might degrade with time. Fertility concerns might arise years later, even if they were not seen before.

• My teenage son was diagnosed with a varicocele. Should this be fixed?

Teenage treatment is case-by-case. It is quite beneficial to discuss options with a urologist or pediatric urologist. Varicocele correction in a teen may be appropriate if there is discomfort, one testicle is much smaller than the other, or the kid has an abnormal semen analysis conducted at the age of 16 years. Some people choose repair in order to avoid future reproductive concerns. In older teenagers, sperm testing can be performed to see whether repair might be beneficial.

• I have no symptoms, but wish to have children. Should I have my varicocele repaired?

Varicoceles with no symptoms are usually not corrected. Most doctors do not feel that if these varicoceles are not treated, they will create health complications. If there is concern about fertility, sperm analysis can be performed to determine whether the varicocele is affecting sperm quality.

• I have pain with my varicocele. What can I do to ease the pain?

Varicocele discomfort can be relieved by wearing jockstrap or briefs-style underwear that supports the scrotum. Lying on your back allows the varicocele to drain and frequently relieves discomfort. Pain relievers (such as acetaminophen and ibuprofen) may also be beneficial. You can also discuss varicocele repair with your urologist.

• I am thinking about having my varicocele repaired for fertility reasons. How long will I have to wait to see if my semen quality improves?

Semen analysis is frequently performed three to four months following the surgery. Semen quality usually improves after six months, but it might take up to a year.

• I found a lump on my scrotum during a self-exam. Should I worry?

Abnormalities in the male reproductive tract might manifest as a scrotal lump. Masses may not be a cause for concern and may have minimal impact on your health. They might also be an indication of a potentially fatal sickness. Finding out what is causing your bulk is quite beneficial. Testicular carcinoma is one sort of mass. This is reason for alarm and for immediate action. It is critical to consult a doctor if you discover a lump or bulge in your testicle.

Conclusion 

Varicoceles are enlargements of the pampiniform plexus veins in the scrotum. These veins are similar to varicose veins. Most varicoceles are discovered by chance and do not require treatment unless they are symptomatic. Varicoceles can cause discomfort, difficulty fathering a child, or one testicle to develop slowly or decrease. Varicoceles in infertile individuals provide a chance to quickly enhance sperm count and function, which should not be disregarded if present.