Varicocele – All you want to know

What is varicocele?

A varicocele is an abnormal enlargement or engorgement of the veins within the scrotum. They are the veins which drain the blood from the testicles.

You may have heard of or seen varicose veins of the legs  which are abnormally engorged and tortuous veins in the legs. A varicocele is a similar to varicose veins of the legs. It is an enlarged testicular vein. The meaning of Varicocele is varicose veins of testes.

Mostly varicoceles develop over time. It usually begins to form during puberty. About 15% of men are affected by varicocele. It is more common on the left side of the scrotum due to anatomical factors.

The varicosities of veins in the scrotum develop as a result of persistently high pressures in the veins due to inadequate drainage or back pressure. Varicoceles may enlarge over time.

Varicocele may be of various degrees. The grading of varicocele is based mainly on the size. The different grades of varicocele are:

• Subclinical varicocele – There is no visible or palpable varicocele but it can be detected by Doppler ultrasound
• Grade 1 – There is no visible varicocele but it can be palpated on voluntarily increasing abdominal pressure or exerting.
• Grade 2 – There is no visible varicocele but it can be palpated well.
• Grade 3 – Varicocele is visible through the scrotum.

What is the main cause of varicocele?

The exact cause for developing a varicocele is not known. The reason for varicocele is considered to be mostly anatomical. There are various contributing anatomical factors.

Varicocele causes:

• Veins have valves to ensure unidirectional flow of blood. The unidirectional or anti-reflux valves ensure that blood only flows away from the organs and prevent backflow of blood towards the organs. The scrotal veins carry the blood away from the testes and drain into the inferior vena cava. If the valves between the scrotal veins and the inferior vena cava are dysfunctional ,backflow of blood into the scrotal veins happens. The backflow leads to increased pressure in the scrotal veins leading to their engorgement.
• On the left side ,the scrotal veins drain into the inferior vena cava via the left renal vein whereas on the right side the scrotal veins drain directly into the inferior vena cava.

The angle at which the left testicular or scrotal veins enter the left renal vein may be a contributing factor to formation of varicocele. This is the reason why left sided varicocele is more common.

• The left renal vein may get compressed between the two major arteries of the abdomen. That will lead to increased pressure within the the left renal vein. It will lead to back pressure being exerted in the scrotal veins. The scrotal veins may get engorged due to back pressure. This also may be a reason for left sided varicoceles being more common.
• Varicocele on one side may lead to varicocele on the other due to transmission of pressure via communicating blood vessels.

Risk factors for developing varicocele:

Though no definite risk factors for developing varicocele have been identified till date, few studies have attempted to look for hereditary behavior of varicocele.

Is a varicocele hereditary?

Few studies are suggestive of a significant increase in varicocele prevalence in the first degree relatives of men with varicocele. Hence it is advisable to counsel patients with varicocele about the increased risk of varicocele in their male relatives.

Usually men with varicocele are asymptomatic. Many a times the varicocele is detected during evaluation of infertility. Varicocele has strong association with infertility. About 40% of men with infertility issues are found to have varicocele.

Can varicocele cause pain?

Sometimes men may experience heaviness and pain in the scrotum. The pain may be sharp to dull aching. The pain may increase on standing up for prolonged hours or on physical exertion. The pain may worsen during the course of  a day. Pain may relieve on lying down on the back.

In some cases, varicocele may be large enough to be noticed by the person himself. It may be in the form of a swelling above the testicles and within the scrotum. Sometimes a difference in the size of the two testicles may also be a reason to seek medical opinion.

When the doctor examines the scrotum, the varicocele may feel as if a bag of worms. The engorged and highly coiled scrotal veins feel like worms within the scrotal bag.

How is varicocele diagnosed?

Initially a clinical examination may point towards presence of varicocele. The varicocele is mostly palpable to the clinician.

A colour flow Doppler ultrasound scan is the diagnostic method of choice.

CT scan of the abdomen and pelvis may be done if further evaluation of the varicocele is needed.

Complications that arise out of Varicocele:

Varicocele has found to have detrimental effects on sperm function. It has been found to negatively impact sperm concentration, sperm motility and sperm morphology. There are various theories which explain the possible causes for the harmful effects of varicocele on sperm quality. Pressure effects, oxygen deprivation, heat injury and toxins are the various theories put forth by researchers. The elevated heat effect caused by impaired blood circulation appears to be the most consistent hypothesis. The defective sperms may lead to male infertility. Most men with varicocele present to the doctor for the first time with infertility issues.

In men with a varicocele, if the initial semen analysis is abnormal, there is higher risk for further deterioration in semen quality.

Shrinkage of the affected testicle may occur due to impaired sperm producing function. It is termed as testicular atrophy. Testicular atrophy causes the testicles to reduce in size and soften in consistency.

If varicocele develops early during pubertal stage, the testicles may fail to develop properly.

We would like to elaborate on a few frequently asked questions regarding varicocele.

Can a man with varicocele get a woman pregnant?

As explained, men with varicocele may face fertility issues due to poor sperm quality but some men remain fertile despite varicocele, meaning they are able to get a woman pregnant. Male infertility is not the rule with varicocele. But if a man presents with infertility and a varicocele is detected, it should be managed before further evaluation or treatment for infertility.

Can varicocele lead to erectile dysfunction?

Though varicocele is known to affect the sperm quality and fertility, it is not found to be a cause of erectile dysfunction.

Can a varicocele affect testosterone levels?

Some recent studies show that men with varicocele have impaired testosterone production. Besides sexual problems, low testosterone levels cause problems such as:

• low energy levels in men
• decreased muscle strength
• osteoporosis and
• changes in cognitive and psychological function, particularly leading to depression.

The good news is that varicocele microsurgery can improve testosterone levels significantly.

Treatment for varicocele

If asymptomatic varicocele may not need any treatment. Many men with varicocele are even able to get a woman pregnant, meaning they are fertile.

The purpose of treating a varicocele is to tackle pain if any or in case its leading to testicular atrophy or infertility.

Medical treatment for varicocele:

No proven medical therapy for varicocele is under practice till date.

How to fix a varicocele problem?

The treatment of varicocele is surgical. Varicocele surgery aims to cut off the blood flow through the varicocele and redirect the blood into normal veins. Varicocelectomy is the surgical procedure. It involves ligating or tying of the engorged veins and removing excess venous tissue.

When is varicocele surgery necessary?

Varicocele repair or surgery is needed in case of :

• abnormal semen analysis at the time of detection of varicocele
• unexplained male infertility
• scrotal pain
• progressive failure of testicular development in adolescents with varicocele,documented by serial clinical examination

Open surgery

It is a day care procedure which may be done under local anesthesia or general anesthesia. The varicocele is accessed either through an incision over the groin or the abdomen. The procedure may be guided by ultrasound for better localization.

You may be able to resume routine, non-strenuous activities within two days of the procedure. Post procedure pain can be tackled with pain killers.

You may be advised to refrain from sexual intercourse for a few weeks.

Laparoscopic surgery

The varicocele repair is done laparoscopically under general anesthesia. It refers to keyhole varicocele repair and makes use of a very small incision.

Varicocele microsurgery

Microsurgery for varicocele is done with the help of an operating microscope.It is done through a small inguinal or subinguinal incision.It is associated with far less complications when compared to traditional varicocele surgeries.

Percutaneous embolisation

Varicocele embolisation involves coagulating the blood within the engorged scrotal veins which will ultimately lead to scarring of the veins and blockage of varicocele. A solution or coil is released into the scrotal veins via cannula inserted through large veins in the groin such as the femoral vein. It is the least invasive surgical treatment for varicocele. The veins are visualised on a monitor by administering contrast dyes.

Complications of varicocele surgery:

• Hydrocele may occur post operatively. It is a collection of fluid around the testes .
• Infection may occur as in any other invasive procedure
• Accidental ligation of an artery may be dangerous and warrants immediate attention and treatment
• There may be recurrence of varicocele following surgical correction. Recurrence rates are lowest with microsurgical varicocelectomy.
• Post operative complications in percutaneous embolisation may be rare but may be dreadful, such as contrast allergies, arterial injury, thrombophlebitis and coil migration. Thus percutaneous embolisation technique is reserved for recurrent varicoceles after open surgical repair.

Is it necessary to have surgery for varicocele?

Treatment is generally required in case of infertility, testicular atrophy and persistent pain. If pain is the sole problem, conservative management methods such as analgesics and anti-inflammatory drugs may be tried first, apart from wearing snug underwear or jock straps.

In case of infertility, surgery for varicocele should be priority before further evaluation and treatment for infertility. In men with azoospermia who require testicular sperm extraction for In-vitro fertilisation, varicocele repair improves sperm retrieval rates.

Besides, in men with a varicocele, if the initial semen analysis is abnormal, there is higher risk for further deterioration in semen quality if untreated.

Surgery is also indicated if testicular atrophy is evident.

If the thought of invasive procedures is putting you off, you must be wondering if there are any natural remedies for varicocele. us try answering the question for you.

Can varicocele be cured naturally?

The fact is that varicocele cannot be cured completely without invasive procedures. But, few home remedies could keep the pain and engorgement associated with varicocele under check. What are the things you could do to reduce engorgement of the scrotal veins and the pain in varicocele?

• Wearing snug underwear or jock straps
• High fibre diet to prevent constipation. Constipation will lead to straining while passing stools resulting in increased intra-abdominal pressure. High intra-abdominal pressures will worsen the engorgement of scrotal veins due to back pressure. Drinking plenty of fluids will also help soften stools. The engorgement inturn will lead to worsening of pain.
• Avoiding strenuous activity such as running and lifting heavy weights so as to prevent raised abdominal pressures and venous engorgement.
• Avoiding prolonged hours of staying in upright position.An upright standing or sitting position will result in venous pooling in the lower body and engorgement of scrotal veins.
• If the pain is severe ,one can try over the counter painkillers or anti inflammatory drugs.
• Cold compresses mind to the groin may also help relieve pain associated with varicocele.It should be kept in mind that icing the groin should be done over a cloth and never directly.
• Use of athletic supporter

Now that you have read about every aspect of varicocele, you may have thoughts on your mind of how to prevent the development of varicocele. So let us try to understand if varicocele can  be prevented.

Are there any ways to prevent development of varicocele?

Unfortunately, no, there are no ways by which you can prevent development of varicocele. If a person is prone to developing varicocele due to certain anatomical factors, it cannot be prevented. Early treatment may help in avoiding dreaded complications such as infertility and testicular atrophy. In case of normal fertility and testicular function, worsening of symptoms of engorgement and pain in the scrotum may be prevented by adopting the home remedies mentioned before.