Varicocele

Varicocele is the the presence of dilated, or enlarged groups of veins in the scrotum. These dilated veins are filled with excess blood, which can become a problem.

If you’re familiar with varicose veins in the legs you can think of varicoceles as the same condition, just in the scrotum.

Understanding Varicocele and Blood Flow

First, a little background on how the blood flow works and its relation to varicoceles. Every part of the body needs oxygen. Blood carries oxygen to various parts of the body through arteries. Arteries have muscular walls that pump the blood away from the heart.

Veins are the channels that bring the blood back to the heart, and they do not have thick, muscular walls. Their walls are fairly thin, and the blood in them moves more passively. It is pushed back toward the heart through the pressure of the blood being pumped away from the heart and the movement of the muscles and other structures surrounding the veins pushing against the vein walls.

Interspersed along the veins are a series of one-way valves. These valves allow the blood to flow toward the heart but stop the blood from “slipping” backwards. If these valves are not working properly, blood will flow backwards and, because of gravity, the blood will collect in the most dependent (lowest) part of the pathway.

In people who have large varicose veins in their legs, the valves are not functioning properly and the blood is actually pooling in their legs. Because of this, they will find that after standing for long periods of time, the blood has collected in their legs, giving them a heavy, dragging feeling. Men with varicoceles may notice a heavy, dragging, aching feeling in the scrotum (“ball sack”) at the end of the day. There, too, the valves in the veins that drain the blood from the testicles (the internal-spermatic veins) are not functioning properly and allow the blood to collect.

Symptoms of Varicocele

Symptoms of varicocele include infertility, low quality sperm, low sperm count, discomfort in the scrotum, heavy dragging feeling in the scrotum, and low testosterone.

Causes of Varicocele

Varicoceles most commonly develop during adolescence when the testes grow dramatically and therefore need more blood delivered to supply the increased need for oxygen and nutrients. Since more blood is going into the testes, there is also more blood draining away from them. If the valves do not function properly, the extra blood cannot be handled by the veins, and the blood pools in the scrotum.

If large varicoceles develop in a man after adolescence, he must be examined to make sure that there is no tumor in the abdomen pushing and compressing the veins, making the blood unable to properly flow back to the heart.

Some ways this condition may affect you are:

  • Varicoceles may cause infertility through a significant decrease in the quality and quantity of the sperm.
  • Varicoceles may cause damage to the testicles; they may not grow appropriately.

This damage is progressive; it will often worsen over time. If an adolescent has a one-sided varicocele, the testis on that side may not develop as much as the other side and may be significantly smaller. This is a serious consideration because smaller testes generally produce significantly less sperm than normal sized testes. If the varicocele is repaired during adolescence, the testis may experience catch-up growth and normalize in size. If it is repaired at a later age, the testis will not improve in size, though it may often improve in sperm production. The sperm production, however, will still not improve to the same extent it would have had it been repaired earlier.

  • Varicoceles may cause discomfort leading to a heavy, dragging feeling in the scrotum.
  • The testis, besides making sperm, also makes testosterone, the main male hormone. Testosterone is responsible for a man’s “secondary male
    characteristics” (i.e., increased muscle mass and tone, level of sexual interest, body hair). Varicoceles can damage the cells that make testosterone and may lead to a decreased overall testosterone level.

Fifteen percent of all men have varicoceles. (This was measured by examining military recruits, who represented a good cross section of men mostly before they had tried to father children.). However, forty percent of men who are experiencing “primary infertility” (have never fathered a biological child) have varicoceles.

Eighty percent of men with secondary fertility (they have fathered at least one biological child, but are not currently able to do so) have varicoceles. This may be due to the fact that varicoceles cause progressive damage to the testicle and a progressive decrease in the quality and quantity of sperm produced.

Of those men who have varicoceles, forty-five percent have varicoceles on both sides; fifty percent have a left-side varicocele; and five percent have a varicocele on the right side alone.

Varicocele and Infertility

Although we know that varicoceles definitely decrease fertility we’re still not positive why this is so, but there are several theories:

Increased temperature of the testicles.

The testicles are located in the scrotum, which effectively regulates their temperature. They maintain at a temperature slightly below body temperature. (This is probably why they are located outside the body rather than inside the body where they clearly would be better protected.) In cold weather, men may notice their testicles move close into the body as the muscles in the scrotum wall (the cremasteric muscles) tighten. In warm weather, the cremasteric muscles relax and lengthen, allowing the testicles to hang away from a man’s body and cool down.

Some babies are born without their testicles having descended into their scrotum. They are trapped somewhere in their bodies and constantly exposed to body temperature. This is so harmful for the testicles that if they remain there past puberty, they will stop producing sperm altogether and have a higher chance of developing cancer. Therefore, if a boy’s testicles do not descend into the scrotum by the time he is 12 months old, they should be surgically brought down and placed into the scrotum.

Varicoceles are a group of dilated veins filled with blood, that surround the testicles. The blood is at body temperature, and if the testes are near these veins, they will be kept at a higher temperature than is beneficial for them. Even if a man has a varicocele only on one side, the whole scrotum is warmed by the blood and both testicles can be negatively affected.

In general, larger testicles make more sperm than smaller testicles. Often, however, you see men who have a large one-sided varicocele that has damaged
the testis on one side, making it smaller. The small testis makes significantly less sperm than the normal one. However, even in the “normal” one, the sperm quality is often very low. The varicocele is not only damaging the testis on the side where it is found, but also suppressing the sperm production on the opposite (better) side.

When a varicocele is repaired, the blood is no longer able to flow back into the scrotum. This affects not only the testes on that side, but also the opposite side.
With this normalization of temperature, there may be some dramatic improvement in sperm production. It is likely that this improvement comes mostly
from improved production in the larger, better testicle.

Increased waste products back-flowing into the testicle.

The veins draining the testicles connect into larger veins. On the left side, they drain into the kidney vein, which is draining blood from the kidney. The blood from the kidney carries waste products, which may then drain backwards into the scrotum and collect there. This may negatively affect sperm production.

It used to be thought that a varicocele would result in a stress pattern that would appear in the semen analysis (i.e., a decreased percentage of moving sperm or sperm with abnormally shaped heads). Recent studies conclude that varicoceles affect virtually all of the parameters in a semen analysis (i.e., the concentration, motility, forward progression, and morphology). The varicoceles also affect the functioning of the sperm, although this cannot be tested by a routine semen analysis. Very specialized testing of the sperm functioning may be performed, although this is expensive and its use is debated.

Diagnosing Varicoceles

There are three primary ways to diagnose varicoceles: self diagnosis, diagnosis and testing.

Self Diagnosis

Many men know they have a varicocele because they can feel the mass of dilated veins in the scrotum. This feels like a sac of worms or spaghetti. These men have larger varicoceles. They may also notice:

The testicle is smaller on that side.

They have discomfort in that testicle or side of the scrotum.

Diagnosis

During a physical examination a physician may diagnose a varicocele. It can most clearly be felt when a man is standing and again, it will feel like a bag of spaghetti. It may disappear when a man lies down (as the weight of the blood and the veins is no longer pushing down past the malfunctioning valves into the scrotum). In a standing position, the man may also be asked to bear down (like he is having a bowel movement). The physician may feel an impulse when the blood pushes backwards (because of the increased pressure inside the abdomen) into the scrotum.

Testing

Ultrasound: The duplex ultrasound is currently considered the best non-invasive way to identify or confirm the presence of varicoceles. The duplex ultrasound has two parts.

First a thorough ultrasound of the testis is performed. The diameter of the veins can be measured. Other abnormalities may be identified. A recent study found that thirty one percent of men

Treating Varicocele

Varicocele Embolization

Varicocele embolization is an incision-less procedure where we thread a catheter through blood vessels in the groin to the site of the varicocele. The physician then deploys a blocking fluid or a small coil through the catheter blocking the varicocele-causing vein and diverting blood to healthy veins.

A venogram is performed before and after the procedure, to demonstrate outcome by comparing the two images to ensure a successful result.

Varicocele embolization safely relieves pain and swelling and may improve sperm quality.

NYC Surgical Associates performs varicocele embolization as an outpatient procedure using x-ray or fluoroscopic guidance.

Recovery

Recovery time is shorter with varicocele embolization than with surgery. Patients may go home and resume most activities immediately after the procedure (subject to use of sedation).

Often a significant improvement in pain is apparent within the first few days post procedure, and no downtime is needed. Patients can resume work and normal activities the following day, even after IV sedation.

In addition, recurrence of varicoceles is much lower with varicocele embolization than with surgery.