Varicocele

What is Varicocele?

Varicocele is varicose veins in the venous network surrounding the spermatic cord. Varicocele is based on disturbances in venous blood flow as a result of leaky vein valves and occurs on the left side in 90 percent of cases for anatomical reasons (unfavorable entry path from the left testicular vein into the left renal vein). Right-sided varicocele is often combined with left-sided varicocele. Secondary varicoceles can develop due to increased pressure in the posterior abdominal cavity caused by tumors (e.g. kidney tumors).

Children under 10 years of age are rarely affected, with varicocele becoming more common with the onset of puberty. About 15-20 percent of all adolescents are affected. Increased pressure and dilation of the veins surrounding the testicles can damage the testicles, which can lead to reduced fertility.

Varicocele is usually asymptomatic. If there are complaints, urgent examination is necessary. It is not uncommon for affected patients to be noticed during the clarification of an unrealized desire to have a child or discovered by chance during preventive check-ups at the pediatrician.

A scan of the external genitalia and ultrasound examination while lying and standing is necessary to make the diagnosis. Enlarged veins can be seen on ultrasound and testicular volume can be measured.

A varicocele can be divided into four degrees of severity:

1. Grade 0: Varicocele can only be detected by ultrasound (Doppler)
2. Grade I: Varicocele is felt when pressed
3. Grade II Varicocele palpable
4. Grade III Varicocele visible

Causes of Varicocele

Presumably, there are various reasons for dilated veins in the scrotum, for example anatomical ones: when the scrotal vein in the pelvis joins the renal vein at almost a right angle, blood flows more slowly. This can cause blood to pool in the scrotum and cause varicocele. If the angle of union is not favorable, it is usually on the left side – which is why varicocele is more common on the left. Other possible causes of varicocele are congenital weakness of the vein wall and – similar to other varicose veins in the body – weakening of the venous valves.

A tumor in the pelvis or abdomen is rarely the cause: it can put pressure on the vessels and disrupt blood flow. If this leads to obstruction in the testicles, it is called a “symptomatic” varicocele to distinguish it from a “normal” varicocele.

The exact causes of the disease are unknown. However, we know that about 80-90% of varicoceles occur on the left side. It is therefore hypothesized that the specificity of venous blood flow from the left testicle plays a role. This, together with a congenital or acquired weakness of the valvular apparatus of the veins, can lead to the accumulation of blood up to the scrotum and the subsequent formation of varicose veins.

In rare cases, however, varicocele can also be caused by tumors in the abdomen.

Varicocele Symptoms

In most cases, a varicocele does not cause any direct symptoms. Sometimes, however, affected men have swelling, a feeling of tightness or dull, pulling pain in the testicles.

Varicocele can also impair fertility and be the cause of unwanted impotence.

How is Varicocele Diagnosed?

Varicocele is usually visible to the naked eye and can be felt with the fingers. The patient should be examined while standing and lying down. The next step in the diagnosis is an ultrasound examination (sonography), which should cover the testicles as well as the kidneys and certain areas in the abdomen.

Varicocele can be treated surgically. In the outpatient procedure, there are options to block the vessels microsurgically or to remove the outlet blockage with an adhesive agent (sclerotherapy).

Varicocele Treatment Methods

In most cases, a varicocele can be left untreated. But if it affects the fertility of a man who cannot have children, the doctor may recommend treatment.

The affected vessel is closed so that blood can flow through neighboring, healthy vessels. There are two ways to do this:

• Stent
• Surgery

The vein is closed with medication or special small metal spirals. They are introduced into the vein through a catheter and cause a blood clot to form in the varicose vein and close it.

Sclerotherapy works in a similar way: A medicine attacks the blood vessel wall so that the vessel sticks together. This procedure is also called sclerotherapy.

If varicose vein surgery is performed, the doctor separates or ligates the swollen vein and the neighboring small veins. As an “open” operation, the intervention is performed through a larger incision, for example in the scrotum or groin.

Treatment of varicocele can also lead to complications. Bleeding, wound infections, nerve injuries or swelling of the testicles, called hydrocele, are possible.

The principle of all treatment methods is to prevent the blood from flowing back in the wrong direction (reflux) in the testicular veins by blocking or ligating these veins. Therefore, any effective varicocele treatment initially results in the veins filling with blood, the contents of which must be broken down by the body over many months, thus eliminating the enlarged testicular varices.

A less invasive treatment is antegrade sclerotherapy, in which the vessels in the testicles are closed by injecting a sclerosing agent. This procedure can only be performed with the help of X-rays and is usually unsuccessful in the case of a significant third degree varicocele.

Microsurgical varicocele surgery is a very gentle and effective procedure. The vessels are ligated under a surgical microscope and at the same time all other structures of the spermatic cord are safely preserved, so the efficacy is very high and the complication rate is very low. This technique is often the only possible form of treatment, especially in case of recurrence (relapse or persistence of testicular varicose vein) and is rightly considered the best treatment for varicocele.

Complications of Varicocele

Varicocele leads to chronic overheating of the testicular tissue, which can have various effects, such as:

• Testicular atrophy;Testicular volume can be significantly reduced compared to the sides.
• Infertility;The reason for this is not fully understood. However, it appears that a varicocele can affect sperm production and quality.

Development of Varicocele

Due to blood congestion, there is an increase in temperature, increased pressure and possibly circulatory disorders in the testicles. These factors can cause permanent damage over a long period of time. Sperm production and, in rare cases, testosterone production may be impaired.

Varicocele is a special case in young patients who are still in puberty. Here, the affected testicle may experience a significant growth retardation compared to the opposite testicle.

Summary:

• Varicose veins in the scrotum are called varicoceles.
• Similar to varicose veins in the legs, varicoceles develop when blood builds up in the veins and they become permanently enlarged.
• A varicocele forms in the plexus of veins along the spermatic cord.
• Experts assume that between 5 and 15 percent of all men have varicoceles.
• If a man who cannot have children has a varicocele, doctors sometimes recommend treatment to increase fertility.