Varicocele

VARICOCELE OR DILATED VEINS AROUND TESTICLES

The scrotum is a skin-covered sac that holds a man's testicles. It also contains the arteries and veins that deliver blood to the reproductive glands. A vein abnormality in the scrotum may result in a varicocele.

A varicocele is an enlargement of the pampiniform plexus. Those are the veins within the scrotum.

A varicocele only occurs in the scrotum and is very similar to the varicose veins that can occur in the leg. A varicocele can result in a decreased sperm production as well as the quality, which in some cases can lead to infertility. It can also shrink the testicles.

Varicoceles are quite common. They can be found in approximately 15 percent of the adult male population and around 20 percent of adolescent males. The condition is found more commonly in males aged 15 to 25.

This condition, generally forms during puberty and are more commonly found on the left side of the scrotum. The anatomy of the right and left side of your scrotum isn't the same, it differs. Though varicoceles can exist on both sides, it's extremely rare. It is not all varicoceles that affect sperm production.

WHAT HAPPENS NORMALLY

The male reproductive system makes, stores, and moves sperm. The scrotum is the sac of skin that holds the testicles (testes). The hormone testosterone and sperm are both made in the testicles. Sperms mature while moving through a coiled tube (the epididymis) behind each testicle.

Sperm travel to the prostate from each epididymis through a tube called the vas deferens. When a man ejaculates, seminal fluid mixes with sperm in the prostate to form semen. The semen travels through the urethra and comes out from the end of the penis.

A cord called the spermatic cord holds the vas deferens and the testicular artery, which brings blood to the testicle. The same cord also houses the pampiniform plexus, a group of veins that drains the blood from the testicles. The testes need a certain body heat that is below our core body heat for optimal sperm production, maturity and function. The body's heat in the scrotum is about five degrees lower than that of the belly or pelvis. This is due to the presence of the pampiniform plexus, which acts as a counter-current heat exchanger. It works by cooling blood in the testicular artery before it enters the testicles. This helps keep the testicles at the body heat needed to make good quality sperms. When these veins become enlarged such as in varicocele, the overheating of the testes can lower sperm production and function leading to a lower fertility potential.

Fast facts on varicoceles

• The exact cause is yet unknown, but it may be similar to that of varicose veins.
• They are usually not painful.
• Varicoceles are similar to varicose veins but they affect only the testicular area in men.
• Studies reveal that they affect 15 percent of men, usually between the age of 15 and 25 years.
• Varicoceles are not usually serious, but the condition complicates infertility problems.
• Surgery is possible, if complications arise.

CAUSES

One of the explanations for varicoceles is that the valves in the spermatic cords, that carry blood to and from the testicles, stop working correctly.

Again, why this happens is not entirely clear, but it is similar to what happens when varicose veins occur in the leg.

There are one-way valves in the veins that should always allow blood to flow toward the heart. When the valves are faulty it disrupts the blood flow. The blood consequently pools rather than moving smoothly on. This build-up of blood is what causes the vessels to dilate.

As with any other organ, a disruption in blood flow can eventually stop it from working, or working properly.

Varicoceles are classified as:

Pressure type: When the spermatic vein fills up with blood, giving rise to a grade I varicocele.

Shunt type: When there is a severe buildup that causes damage to the spermatic vein and other veins, leading to a larger, grade II or III varicocele.

The left testicle is most likely to be affected. However, even if only one side contains a varicocele, this can impact sperm production on both sides.

SYMPTOMS

Varicoceles rarely cause pain, but if they do, the pain will probably:

• Be worse when the person is standing or during physical exertion.
• Vary between sharp to dull pain
• Decrease when the person is lying on his back
• Worsen as the days go by

Often times, varicoceles will go unnoticed, but a physician may notice them during a medical examination.

However, the individual should see a doctor if they notice:

• Changes in the size, shape, or appearance of the testes
• A lump
• Fertility problems
• Swelling in the scrotum
• Veins that show as unusually large or twisted

RISK FACTORS

They are most likely to appear during puberty, but there are no particular risk factors known for varicoceles.

Being overweight may reduce the risk, while being taller appears to increase it.

It was previously thought that once a man has fathered a child, he is unlikely to be infertile after this, but researchers have concluded that this was probably not entirely true. Instead, they suggest that the risk of infertility may actually increase over time.

If varicoceles develop in a man who is for instance aged over 40 years, it is more likely to be due to a blockage in a larger vein in the abdominal area, more possibly as a result of a kidney tumor.

COMPLICATIONS

In some cases, a varicocele can lead to complications.

Infertility

Infertility is the most serious complication that can occur from varicocele. It occurs most likely because the increased amount of blood in the region raises the temperature of the testicles.

Between almost half of all men with primary infertility condition have varicoceles. Primary infertility is when a couple have not successfully conceived after 12 months of trying.

Varicoceles also affects most men with secondary infertility. This is when a couple has been able to conceive at least once but are no longer able to do so.

A recent research published that, close to sixteen percent (16%) of healthy young men who were surveyed over a period had varicoceles. Those with varicoceles also had poorer semen quality.

Sperm production is most efficient at a temperature slightly lower than body temperature.

Shrinkage of testicle

A varicocele can result in testicular atrophy, or shrinkage. Sperm-producing tubules make up the bulk of the testicle. If they are damaged, the testicle might become smaller and perhaps even softer.

Hormone imbalances

As the cells react to the increase in pressure, some changes in hormones can result. There may be higher levels of luteinizing hormone (LH). This hormone is present in both men and women, but it is higher in women. There also may be normal-to-subnormal levels of testosterone.

WHEN TO SEE A DOCTOR

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

However, if a person experiences:

• pain in the scrotum
• swelling in the scrotum,
• discover a mass on your scrotum,
• notice that your testicles are different sizes, or
• develop a varicocele in your youth, or
• you're having problems with fertility,

They should contact their doctor. A number of conditions can cause a scrotal mass or testicular pain, some of which may require immediate treatment.

DIAGNOSIS

Both the patient and the doctor may be able to feel the mass easily. Otherwise the doctor might ask the patient to stand, take a deep breath, and hold it while you bear down. This is known and called the Valsalva maneuver. It helps them feel enlarged veins.

Doctors might still take an ultrasound of the scrotum if the exam isn't conclusive. A scrotal ultrasound uses sound waves to take pictures of the inside of your body. The pictures can tell the doctor how large the veins in the scrotum are, how large the testicles are, and which direction the blood is flowing in your scrotal veins.

The size of the lump in the testicle will help the doctor classify the varicocele on a grading scale of 0-3.

A Grade 0 is the smallest, and can be seen only with the help of an ultrasound.

Grade 3 is the largest, and means your varicocele is big enough that it changes the shape of the scrotum.

TREATMENT

Treatment might not be necessary for varicocele. Many men with varicoceles are able to father a child without any treatment. However, if the varicocele causes pain, testicular atrophy or infertility or if you are considering assisted reproductive techniques, you might want to undergo repairs for the varicocele.

The purpose of surgery is to seal off the affected vein to re-direct the blood flow into normal veins. In cases of male infertility, treatment of a varicocele might improve or cure the infertility or improve the quality of sperm if techniques such as in vitro fertilization (IVF) are to be used.

Clear indications to repair a varicocele in adolescence will normally arise from the results of;

• A progressive testicular atrophy,
• Pain
• An abnormal semen analysis

Although treatment of a varicocele generally improves sperm characteristics, it's not clear if an untreated varicocele leads to a progressive worsening of sperm quality over time.

Varicocele repair presents relatively few risks, which might include:

• A buildup of fluid around the testicles (hydrocele)
• A recurrence of varicoceles
• An infection
• Damage to an artery

Repair methods include:

Open surgery.

This treatment usually is done on an outpatient basis, and during general or local anesthetic. Commonly, the surgeon will approach the vein through the groin (inguinal or sub-inguinal), it's also possible however, to make an incision in the abdomen or below the groin.

Advances in varicocele repair have led to a massive reduction of hitherto, post-surgical complications.

One of such 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.

A person might be able to return to normal, non-strenuous activities after two days. As long as he is comfortable. He might return to more strenuous activity, such as exercising, after about two weeks.

Pain from this surgery generally is mild but might continue for several days or weeks. Your doctor might prescribe pain medication for a limited period after surgery.

After that, the doctor might advise the patient to take over-the-counter painkillers, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others) to relieve their discomfort.

Your doctor might advise against having sex for a period of time. Often times, it takes several months after surgery before improvements in sperm quality can be seen with a semen analysis. This is because it takes approximately three months for new sperm to develop.

Open surgery with the use of a microscope and sub inguinal approach (microsurgical sub inguinal varicocelectomy) has the highest success rates when compared with other surgical methods.

Laparoscopic surgery.

The surgeon will make a small incision in the abdomen and pass a tiny instrument through the incision to see and to repair the varicocele. This procedure normally requires general anesthesia.

Percutaneous embolization.

A radiologist will insert a tube into a vein in the groin or neck through which instruments can be passed. Viewing the 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 isn't as widely used as surgery.

After embolization, you can often return to work after two days, and begin exercising after seven to 10 days.

ADVANTAGES OF VARICOCELE EMBOLIZATION

Varicocele embolization is minimally invasive and usually performed as an outpatient procedure. One does not need to be hospitalized or placed under general anesthesia. Your doctor uses a local anesthetic to numb the affected area, and the patient can return home soon after the procedure.

Varicocele embolization also involves a much shorter recovery time than surgical treatments. Most patients actually return to their normal activities within a day or two. And because there is only a small incision, there is minimal risk of scarring and a reduced risk of infection.

Although a varicose vein in the testicle may have a negative impact on a person's health, the right treatment can help resolve the symptoms.

EFFICACY OF VARICOCELES EMBOLIZATION

Embolization is equally effective in improving male infertility and even costs about the same as surgical ligation. Pregnancy rates and recurrence rates are comparable to those following surgical varicocelectomy. In one research study, sixty out of a hundred who were treated for infertility conceived.

In another study, sperm concentration improved in 83 out of hundred patients undergoing embolization compared to 63 of those surgically ligated. Patients who underwent both procedures expressed a strong preference for embolization.

Recovery Time

An average of one to two days for complete recovery for embolization, as compared to two to three weeks for surgery

24 patients out of hundred surgical ligation patients required overnight hospital stay, compared to none for embolization.

AFTER TREATMENT

Healing after surgery is fast and pain is often mild. One can often return to work after about one week after surgery. It is important to also follow-up with the urologist.

For surgeries done for fertility problems, semen analysis is done three to four months later.

Healing after embolization is also relatively short with only mild pain. Patients should avoid exercise for about two weeks after the procedure though one can often return to work one to two days later. The recurrence rate with embolization is almost similar to that of surgery. But there are cases where embolization is preferred over surgery.

The impact of the repairing of a varicocele on fertility is not clear. Some studies show fertility improves after varicocele repair while other studies don't. Semen quality improves in about more than half of infertile men after varicocele repair. This treatment should be thought about along with other fertility treatment choices.

Catch-up growth may or may not occur in teens, where the main reason for surgery is slow testicular growth.

LIFESTYLE AND HOME REMEDIES

If a person has a varicocele that causes him minor or no discomfort, and does not affect his fertility, he might try the following for pain relief:

• Use over-the-counter painkillers, such as acetaminophen or ibuprofen.
• Wear an athletic supporter to relieve pressure.