Could you have a varicocele without knowing it?
Although it usually causes no symptoms, varicocele “strikes” 10 to 15 in every 100 men.
It usually develops at a young age (15 to 25 years) and is most often noticed much later, following tests for infertility, and mainly after a semen analysis that shows a greatly reduced sperm count.
In the article that follows you will learn about the symptoms and the causes, and about when a patient needs to have surgery to be rid of the varicocele once and for all.
By varicocele we mean a twisting dilatation of the veins of the testicle, caused by venous blood flowing backwards (reflux) in the internal spermatic vein. It is essentially a venous insufficiency (a condition similar to varicose veins in the legs).
Its incidence in the general population is 10-15%, while among infertile men the figure rises to about 20%-40%. In the vast majority of cases the varicocele appears on the left (90%) and only 2% on the right, for anatomical reasons.
Clinical picture - Diagnosis
Clinically, a varicocele appears as a soft mass with ill-defined edges above the testicle on the affected side. Characteristically, it gets smaller when the patient lies down (low intra-abdominal pressure), whereas it gets larger in the upright position and, in general, when intra-abdominal pressure rises (Valsalva manoeuvre), as during exercise or coughing.
The definitive diagnosis of a varicocele is made with a colour Doppler ultrasound scan (triplex).
The classification of varicocele is useful in clinical practice and is as follows:
Subclinical: Not visible, either at rest or when intra-abdominal pressure is raised, but diagnosed on ultrasound as an incidental finding.
Grade 1: Palpable when intra-abdominal pressure is raised, but not at rest.
Grade 2: Palpable at rest, but not visible.
Grade 3: Visible at rest.
Symptoms
Depending on its size, it may cause a feeling of heaviness or discomfort.
It may affect the normal development of the testicle on the same side.
It may affect sperm production (spermatogenesis) and, by extension, fertility.
The exact mechanism by which a varicocele affects spermatogenesis has not yet been established. The most widely accepted theories are the following:
(a) a rise in testicular temperature due to venous stasis (normally, the temperature of the testicle is 2-4° lower than rectal temperature)
(b) reflux of blood from the left renal vein into the internal spermatic vein on the same side, so that toxic metabolites of kidney and adrenal function (mainly catecholamines and prostaglandins) are carried to the left and the right testicle (because of the venous connections between the two halves of the scrotum).
(c) a rise in pressure within the testicle from chronic venous stasis, disturbing the testicular microcirculation.
(d) changes in the hypothalamic-pituitary-gonadal axis, characterised by an increased gonadotrophin response to GnRH with reduced androgen synthesis.
(e) tissue hypoxia due to venous stasis.
Do I need to have it treated?
Because of the possible damage to the testicle, treatment is recommended in the following cases:
In children in whom ultrasound shows delayed growth of the testicle.
In infertile men with abnormalities on semen analysis and no other cause of infertility.
A subclinical varicocele should not be operated on.
Treatment
Treatment of a varicocele is surgical and consists of ligation of the spermatic vein.
In recent years the trend has been towards microsurgical treatment (microsurgical varicocelectomy). The result of the operation should be checked after 6-9 months, to allow time for new generations of sperm to be produced. The rate of improvement in semen quality after surgery is 60-70%.
Alternatively, the spermatic veins can be embolised by injecting sclerosing agents, the drawback of this method being its high recurrence rate.