What is Varicocele? Causes and Treatments

A varicocele is an enlargement of the veins, pampiniform plexus, in the scrotum which drains blood away from testicles. Varicocele commonly occurs during puberty due to the malfunction of the valves in pampiniform plexus. Since the pampiniform plexus also plays an important role in regulating the temperature of the testicles, a malfunction in these vessels can cause defects in sperm production and eventually lead to infertility.

According to the 2022 article, It is estimated that between 15% and 20% of all males have varicoceles, but that number rises to roughly 40% in infertile individuals. It occurs during or after adolescence, between ages 15 to 25, in more than 90% of cases. This is because there is a dramatic increase in blood volume demand by the testicles during puberty. Even while the majority of blood continues to flow normally, blood might begin to pool and cause a varicocele.

Varicocele Causes

Although the main cause of varicocele is still unknown, there is a strong belief that malfunction in the valves of testicular veins might be the main cause.

Normally, testicular veins, called pampiniform plexus, have one-way valves that ensure the blood flows from the testicles back to the scrotum and then to the heart in a healthy individual. However, when these valves are impaired, gravity can make blood pooled in the scrotum, more commonly in the left side, and therefore cause varicocele.

Why is Varicocele More Common on the Left Side?

According to recent studies, varicocele affects the left testicles 80% to 90% more often than the right one. It is because the veins that flow from the testicles to the heart are linked in different ways on the left and right sides. This entails more pressure for the blood to keep moving through the veins toward the heart on the left testicles, therefore, increasing the possibility of experiencing varicocele on the left testicle.

What Increases the Risk of Varicocele?

Varicocele is a common condition that may happen occasionally during puberty in males. There are no apparent risk factors that place males at a higher risk for developing a varicocele.

Varicocele Symptoms

Varicocele rarely shows apparent signs or symptoms. When symptoms do occur, you may experience:

Mild discomfort in the testicles

A mass in the testicle: 

If a varicocele is considerably large, a mass, commonly referred as bag of worms, might be observed in the testicle.

Differences in the size of the testicles: 

The failing testicle may be significantly smaller than the unaffected one.

Infertility: 

A varicocele may induce infertility in some cases, if not all.

Varicocele Diagnosis

Your physician may diagnose a varicocele in a number of methods, including the following:

• Physical checkup: Varicocele is not always associated with physical change in the scrotum but a physical examination is still a valid method to get diagnosed. Your examination will be conducted while standing when your scrotum is relaxed.

• Valsalva maneuver: This method is frequently employed to diagnose minor cases of varicoceles. In order to do the Valsalva maneuver, your urologist will ask you to take a deep breath, hold it, and squat while feeling the scrotum above the testicle.

• Scrotal ultrasound imaging. A scrotal ultrasonography might be needed when physical examination is inconclusive. In such a scenario, this method gives information about the size of the veins in your scrotum, the size of your testicles, and the direction of blood flow in your scrotal veins.

After diagnosis, your doctor grades your varicocele on a scale from 0 to 3 based on the size of the lump on your testicle. A Grade 0 is the smallest and can only be detected by an ultrasound. Grade 3 indicates that your varicocele is so large that it alters the shape of your scrotum.

The size doesn't always change the overall treatment method. Your treatment will be determined by your urologist according to the severity of your condition, the pain you’re suffering and whether you want to solve the problem of infertility, if exists.

Treatment for Varicocele

A varicocele doesn't always need to be taken care of. But you might want to think about treatment if varicocele causes:

• pain

• testicular atrophy, or

• infertility

Varicocelectomy 

There are several ways to perform varicocele surgery. It usually involves blocking the pampiniform plexus veins to direct the blood flow toward normal veins. Surgery is generally conducted under general anesthesia and is done as an outpatient operation.

1. Microscopic varicocelectomy procedure: The surgeon makes a 1 cm incision above the scrotum and ties off all the small veins via a microscope. The surgery takes between 2 to 3 hours.

2. Laparoscopic varicocelectomy procedure: With this technique, the surgeon makes a small incision in the abdomen and inserts a thin tube with a camera into the abdomen to tie the veins off. This is a shorter process that takes about 30–40 minutes.

The pain after surgery is usually mild, and the person can usually do most of their normal activities again within two days. With both microscopic and laparoscopic surgery, pain and time to heal are about the same. According to a recent article, about half of the men who have surgery to fix infertility caused by varicocele can have children within their first year after the surgery.

The possible complications of the varicocele surgery that may occur are:

• persistent and/or recurrent varicocele

• having fluid build up around the testicle

• a damage in the testicular artery

Percutaneous Embolization

Percutaneous embolization is a minimally invasive operation that can be performed instead of surgery as an outpatient procedure. It is commonly performed under local anesthesia.

Procedure for Percutaneous Embolization

• A small cut is made in the skin by an interventional radiologist.

• A small catheter is put into a vein, usually in the groin or neck, through the cut in the skin.

• The catheter is moved into the abdomen and into the varicose vein with the help of x-ray images.

• Small metal coils and a special medicine called a sclerosant are used to close off the vein. Blood flow is stopped to the damaged veins, letting healthy veins take over and return blood flow to normal.

Healing from Varicocele after Treatment

As previously discussed, a person having varicocele surgery can go back to his normal routine within 2 days. However, it is suggested not to work out for up to 14 days after the treatment. You will be required to show up in your follow-up appointments with your urologist and follow his or her instructions for the recovery period. You will be asked to book another appointment for the semen analysis to observe the success of your treatment 3 to 4 months after your operation.

Recovery period for embolization operation is also considerably short with only mild pain. You shouldn’t work out for at least 7 days after your operation. You can return to your normal activities within 1 to 2 days.

Your surgeon may recommend a scrotal support and ice bag application to the incision site to avoid swelling after the operation. There might be slight discomfort in the testicles for a couple weeks, which will ease very quickly after this period.

Both surgery and embolization might be inconclusive treatment due to the possibility of recurrence. However, there are also several scenarios where embolization can be preferred over surgery. Please consult your urologist for the best treatment method for your case.

Varicocele treatment might not be the final solution to a male infertility because of the success status of the operation as well as the condition of the patient. For both scenarios, other treatment and solutions might be considered. You should always consult your urologist to find out the best option for your case during your appointment.