What is a Varicocele?
Varicocele is an abnormal enlargement of the vein that is in the scrotum draining the testicles. The testicular blood vessels originate in the abdomen and course down through the inguinal canal as part of the spermatic cord on their way to the testis. Upward flow of blood in the veins is ensured by small one-way valves that prevent backflow. Defective valves, or compression of the vein by a nearby structure, can cause dilatation of the veins near the testis, leading to the formation of a varicocele.
Normally, blood flows to the testicles through an artery, and flows out via a network of tiny veins that drain into a long vein that goes up through the abdomen. The direction of blood flow in this vein should always be up, toward the heart. A series of one-way valves in the vein prevent the reverse flow of blood back to the testicles.
What causes varicoceles?
The exact cause of varicoceles is unknown. Some researchers believe that the one-way valves in the veins leading from the testes back to the heart may be not working properly. These valves prevent blood from flowing backwards in between heartbeats. When the valves are not working properly, the blood can pool in the veins and cause them to widen or dilate. The same is true for varicose veins in the legs or hemorrhoids in the rectum.
How to Diagnose a Varicocele
Do this simple test to see if you have a varicocele. Take off your clothes. Stand up. Feel your scrotum. Cough several times as you do this. A varicocele becomes more pronounced when you cough. Do you feel any bulging veins?
In the advanced stages, it will feel like a bag of worms. In the early stages, you may feel a few slightly enlarged veins. Some people already feel pain in the very early stages, before the veins become noticeably enlarged.
The veins come down from above and wrap around the testicles, so it may feel as though one or both testicles are enlarged. You have two testicles, one on each side of the scrotum. Each has its own vein supply, and usually only one side will become enlarged, usually the left side.
Each testicle is egg shaped, smaller than most bird eggs, bigger than a marble. It feels something like a hard rubber ball, normally. When surrounded by swollen veins, it may feel softer. You should be able to give it a gentle squeeze without feeling pain. If you feel any pain while squeezing, you may have a varicocele.
Can varicocele cause problems with erections?
A varicocele is a dilation of the spermatic veins in the scrotum. Varicoceles are found in many men, but with a higher frequency in the population of men with infertility. The condition may cause a slight increase in the temperature of the scrotum, which is the proposed mechanism of the sperm abnormalities. Men are frequently asymptomatic from a varicocele, but symptoms can include: mild pain, testicular atrophy or shrinking of the testicle, and possible decreased fertility. Erectile dysfunction is not typically related to the presence of a varicocele. If a man is experiencing erectile dysfunction, a full medical work-up is strongly recommended.
How do varicoceles cause male infertility?
The exact cause of infertility among men with varicocele is not clearly understood, however, researchers believe that varicoceles can cause the testes to retain too much heat, which makes it difficult for sperm to live. The testes function best when they are 3 to 4 degrees C lower than body temperature. The testes remain cooler because they hang outside of the body, but also because of something called countercurrent heat exchange mechanism. As arteries approach each testicle, the blood vessels become very tightly wound like a radiator coil and are normally surrounded by a fine network of veins. This network helps exchange heat, and allows for a cooling of the testes. If the veins become enlarged because of higher pressure in the veins or poorly functioning valves, the heat exchange mechanism does not work properly causing the testes to retain heat and impairing their ability to make sperm.
New research suggests that the excess heat caused by varicoceles may also impair the testes ability to make the hormone testosterone. The enzymes in the testes that are responsible for testosterone production are also temperature sensitive and work best at the same temperature that is best for sperm production. Low testosterone levels may negatively affect sex drive, the ability to get erections, muscle strength, and energy level. In addition, low levels of testosterone have been linked to bone thinning (osteopenia and osteoporosis) and depression in men.
What is the treatment for varicoceles?
Varicocelectomy, the surgical correction of a varicocele, is performed on an outpatient basis.
In this type of varicocele treatment, the surgeon makes an incision above the scrotum (or higher in the flank area) and cuts through the layers of tissue to expose the veins.
The affected veins are ligated, or tied off, to detour the flow of blood into normal veins. Sometimes a laparoscope (a cylindrical metal scope inserted into the abdomen) is used to perform the surgery. Recovery time depends on the type of surgery, but most patients require up to six weeks before heavy lifting and other strenuous activities can be performed. Light activities may be resumed more quickly.
An alternative to surgery is embolization.
This involves passing a small wire through a peripheral vein and into the abdominal veins that drain the testes. Through a small flexible catheter, the doctor can obstruct the veins so that the increased pressures from the abdomen are no longer transmitted to the testicles. The testicles then drain through smaller collateral veins. The recovery period is significantly less than with surgery and the risk of complications is minimised with overall effectiveness similar to surgery, yet with fewer recurrence rates.
What are the advantages of varicocele embolization vs. varicocele surgery?
Unlike varicocele surgery, embolization requires no incision, stitches, or general anesthesia. Further, embolization patients almost never require overnight admission to the hospital. In addition, several studies have shown that embolization is just as effective as surgery. Studies have also shown that embolization patients return to full activities in a day or two, but varicocele surgery patients may need to avoid strenuous activity for several days or even weeks. Some complications of varicocele surgery, such as hydrocele (fluid around that testicle) and infection are virtually unheard of after embolization.
