What Is A Varicocele?
A varicocele is a swelling of the veins in the scrotum that transport blood from the testicles. They are similar in appearance to varicose veins that form in some people’s legs.
10-15% of all males have varicoceles. Varicoceles usually develop during puberty, and may gradually become larger.
Because of anatomical differences between the right and left sides of the scrotum, varicoceles more often form on the left side. Although it rarely happens, varicoceles can sometimes occur on both sides at once.
Varicoceles are typically easy to detect and often don’t require any treatment at all. They are usually harmless and cause little-to-no discomfort.
However, in certain cases a varicocele can be painful, lead to fertility problems, or cause impaired growth of the affected testicle. Varicoceles that cause symptoms can often be surgically repaired.
Do Varicoceles Affect Fertility?
Varicoceles commonly lead to low sperm count and poor sperm quality, which can result in infertility in men. Even so, having a varicocele does not necessarily mean that your sperm production will be affected.
Approximately 40% of men tested for fertility issues have a varicocele and low sperm motility.
Although varicoceles are frequently found in men who are tested for infertility, 80% of men who have a varicocele do not have problems with fertility.
Varicoceles frequently aren’t accompanied by any signs or symptoms. Nevertheless, they can be a cause for concern for a number of reasons, including infertility and impaired growth of the testicle.
Varicoceles can grow larger and more visible over time, and are sometimes described as resembling a bag of worms. Swelling of the testicle can also occur, which is most often located on the left side.
In rare circumstances, a varicocele may cause pain. In these cases the pain often can be described with the following symptoms:
- Pain that can be either dull or sharp.
- Pain that worsens when standing or with physical exertion, especially for long periods.
- Pain that increases as the day progresses.
- Pain that is relieved when lying on your back.
The exact cause of varicoceles is not known, but it is believed that they may form due to malfunctioning valves that hamper blood flow in the testicular veins. If blood is not flowing freely enough through the veins it may pool up, causing the veins to become swollen. This could potentially damage the testicle or impair fertility.
Additionally, the larger veins branching from the testicles are structurally different on each side of the scrotum. To keep blood flowing back towards the heart, more pressure must be applied on the left side.
In rare circumstances, enlarged lymph nodes or other masses in the abdomen can block the flow of blood. When this occurs it is frequently painful.
What Problems Are Associated with Varicoceles
A varicocele might cause the following to occur:
- Testicular Atrophy – Shrinkage of the affected testicle could occur with a varicocele, although the reason why this happens is unclear. However, veins with faulty valve function can cause blood to pool, resulting in increased pressure and toxins that could cause damage to the testicle.
- Male Infertility – Because varicoceles could cause an elevation of temperature around the testicle, it could adversely affect sperm production, motility, and function.
When To See A Doctor
Varicoceles rarely cause symptoms and often do not require treatment. Varicoceles may be found during a routine physical examination or a fertility evaluation.
However, if you have any of the following symptoms, make an appointment to see a doctor:
- Pain or swelling in the scrotum
- A mass in the scrotum
- One testicle smaller than the other
- Complications with fertility.
Certain conditions involving testicular pain or a scrotal mass may require immediate treatment.
Varicoceles can be found by self-examining the scrotum, or during a routine physical exam by a doctor. They are generally identified as being a painless mass above the testicle that is often described as feeling like a bag of worms.
If the varicocele is small, your doctor may ask you to stand, hold your breath and bear down while he examines the area. This technique is referred to as the Valsalva maneuver, and allows your doctor to better detect abnormal swelling of the veins.
Your doctor may order a scrotal ultrasound if the physical exam is not conclusive. A scrotal ultrasound is a sound wave-based imaging procedure to see inside your body, and may be used to confirm there are no other causes for your symptoms.
Varicoceles are identified when an ultrasound shows that the veins are larger than 3 millimeters, and blood flows in the wrong direction during the Valsalva maneuver.
An ultrasound can also reveal the size of the testicles, which can be helpful when determining how to treat teenagers.
Further imaging may be necessary in certain circumstances to rule out other causes of varicoceles, such as a tumor. However, if there are no problems detected during the physical exam, an ultrasound will most likely not be necessary.
Varicoceles often do not require any treatment. However, men with varicoceles can be treated who have the following symptoms:
- Fertility issues
- Impaired growth of the testicle
- Abnormal semen analysis results
While there are no medications available to prevent or treat varicoceles, over-the-counter painkillers such as ibuprofen or acetaminophen may be helpful.
Surgery is an option when necessary (embolization, which involves briefly blocking the veins, is an alternative to surgery).
Surgery is performed to close off the affected vein and re-channel blood flow to normal veins. In situations involving problems with male fertility, varicocele treatment may improve or reverse the condition. Treatment may also increase sperm quality when using assisted reproductive techniques, such as IVF.
In adolescence, testicular atrophy, pain, and/or abnormal semen analysis are clear indicators that the varicocele should be repaired. While treating varicoceles largely improves sperm parameters, it’s unclear whether an untreated varicocele will cause a gradual decline in sperm quality.
There are two types of repair methods: surgery and percutaneous embolization.
Varicocele surgery can be performed in a number of ways. All of them involve blocking blood flow of the testicular veins.
General anesthesia is required for varicocele surgery. Two of the most common surgical methods are microsurgical varicocelectomy and laparoscopic surgery.
A microsurgical varicocelectomy is performed using a microscope to locate the correct veins. This allows the surgeon to easily identify and distinguish between the veins that must be removed from those that should be kept.
The surgeon will make a 1-centimeter cut above your scrotum. The doctor will then tie off the smaller veins and remove the varicoceles. This procedure generally lasts between 2-3 hours, and you can return home that same day.
A microsurgical subinguinal vericocelectomy has the greatest rate of success as compared to other surgical methods.
Laparoscopic surgery is another surgical option. This is a varicocelectomy that uses a thin, lighted tube called a laparoscope. By using this small tube, the surgeon needs only to make a few tiny incisions for the instruments to pass through.
The tubes are inserted through the abdomen, where there are less veins to tie off. A varicocelectomy using this method is fairly quick, taking only 30-40 minutes. You are also able to return home that same day.
Surgery to repair a varicocele has relatively few risks. However, in certain cases complications could arise, such as:
- Hydrocele (fluid buildup in the scrotum).
- Varicocele comes back
- Damage to an artery
A percutaneous embolization is performed by an interventional radiologist. To locate all veins that lead to the varicocele, dye is injected through a tube placed in the groin.
While viewing the affected veins through a monitor, the doctor releases either coils or a solution that creates scarring. The scarring results in a blockage in the affected veins, interrupting the flow of blood and repairing the varicocele.
The procedure can be done using either local anesthesia or mild sedation. It is usually performed in 45-60 minutes.
You can usually return to work within two days following an embolization, and start exercising after 7-10 days.
Embolization has a rate of recurrence that is comparable to that of surgery. However, there are situations where embolization is preferable to surgery.
The healing process following surgery is usually quick with only mild discomfort. Afterwards, you can usually return to work in 5-7 days, but should avoid exercising for 10-14 days. Your urologist will also schedule you for a follow-up appointment. In cases where surgery was performed for fertility issues, a semen analysis will be given 3-4 months later.
Although any pain experienced as a result from this surgery is usually mild, it can last for days or even weeks. You may be prescribed pain medication to use for a short time following the surgery. Beyond that, your doctor may recommend you take over-the-counter medication to ease any discomfort, such as ibuprofen or acetaminophen.
You might be advised by your doctor to avoid having sex for a certain length of time. Because sperm take around 90 days to fully mature, any improvements in sperm quality following surgery will take several months to be seen.
The recovery process after embolization is fairly quick with only mild discomfort. Following the procedure, you can return to work within 1-2 days, but should refrain from exercising for 7-10 days.
It is unclear what effect varicocele repair has on fertility. Some research has shown that fertility increases after varicocele repairs, while other research doesn’t.
Approximately 60% of men with infertility will notice improved semen quality following a varicocele repair. This type of treatment should be considered along with other options for treating fertility.
For teenagers who undergo surgery to repair a varicocele (primarily performed to treat impaired testicular growth), resumption of growth may occur, but may not.