Varicocele

Varicocele is an abnormal & tortuous dilatation of the veins of the pampiniform plexus of the spermatic cord and is most commonly diagnosed by physical exam, (feeling of a bag of worms) or color duplex Doppler ultrasound (where vein measurement and blood flow patterns are observed).  Varicocele rarely becomes clinically evident before early adolescence.  Once present, they are not thought to regress.

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Incidence

15% of all men and 40% of infertility patients are found to have a varicocele. Approximately 90% are left side sided and 10% are bilateral.

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Etiology (Cause)

There are many theories as to the reason varicocele occur: 1) The left internal spermatic vein is 8-10 centimeters longer than the right and acts as a hydrostatic column with increased pressure in the upright position. 2) There are 40% fewer valves in the left spermatic veins as compared with 23% fewer on the right. 3) "Nutcracker Phenomenon" (compression of the left renal vein between major blood vessels) with increased pressure in the left internal spermatic vein.

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Symptoms & Signs

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. 

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Signs of Varicocele

Pain

One of the signs of varicocele 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 or exercising in a gym may make varicocele symptoms worse and, in some cases, can even cause varicocele to form. Usually (but not always) painful varicocele are prominent in size.

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Fertility Problems

There is an association between varicocele and infertility or sub fertility, 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 varicocele 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 varicocele contributes 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. 

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Testicular Atrophy

Atrophy, or shrinking, of the testicles is another of the signs of varicocele. 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.

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Problems Caused by Varicocele

• Elevated scrotal temperatures alter development maturation of sperm.

• Alteration of hormones (messengers) between the hypothalamus (upper brain), pituitary (main message center in the brain) and the testicles.

• Stagnation of blood around the testicles.

• Loss of testicular mass at the microscopic level.

• A varicocele on one side can deleteriously affect that testicle as well as the opposite testicle.

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Semen analyses may show decreased counts, decreased motility (swimming ability), increased number of abnormally shaped sperm, and abnormal sperm function (e.g. on a sperm penetration assay).

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Treatment of Varicocele

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Surgical Varicocelectomy ( Inguinal and Sub inguinal Ligation)

Inguinal Approach is most preferred to prevent recurrence and magnification during the surgery is a must to save the testicular artery.

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1. Benefits:  

   • 100% occlusion rate and 5% recurrence rate

   • 66% of men with improvement in seminal parameters

   • 43% of men achieves a pregnancy

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2. Risks of procedure:

   • 5% Wound infection

   • 3% Epididymitis (inflammation of the epididymis)

   • 3% Hydrocele formation (fluid around the testicle)

   • 1% Nerve injury leading to numbness in groin and scrotum

   • <1% Loss of testicle from damage to the testicular artery

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3. Post-Procedure process: 

   • A semen analysis is checked approximately 3 months after surgical procedure

   • Improvement in some aspect of the semen analysis may be noted soon after surgery and should continue to improve with time

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4. Recommendations after surgery:

   • No heavy  weight  lifting  for 30 days

   • No sexual activity for four week

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Percutaneous Radiographic Embolization

Not recommended.

Mentioned here only NOT to do it.

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1. Benefits:

   • 70% occlusion rate and 5% recurrence rate

   • Diagnosis and treatment of sub clinical varicocele (those not seen or felt on exam). No surgery is required or advised for such sub clinical varicocele.

   • Optimal treatment after surgical failure

   • Immediate recovery/no lifting restrictions  

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2. Risks of procedure (11%):

   • Extravasations (catheter comes out of the vein)

   • Allergic reactions to dye -Inflammation of the veins in the testicles from sclerosing agents

   • Accidental puncture of femoral artery with femoral approach

   • Venous Spasm

   • Pain

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3. Retroperitoneal & Laparoscopic Ligation (Palomos)

This method of treating varicocele has been given up long back as there is high incidence of recurrence of varicocele.

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