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Urologic Pelvic Pain Syndrome

What are Varicoceles?

Varicocele is the abnormal enlargement of veins in the scortum. These veins are called the pampiniform plexus. The scortum is the loose bag that holds the testicles. It also contain arteries and veins to deliver blood to the reproductive glands. Varicocele is very similar to varicose vein that occur in leg. Most of the vaicoceles occur on the left side because of the position of the left testicle veins. If it occurs on both the sides it is called Bilateral Varicoceles. Varicoceles are generally acquire during puberty.

In many cases varicoceles are directly associated with infertility causing low sperm production and decreased sperm quality. Varicoceles also may cause shrinking of testicles. Most of the varicoceles don't need treatment, however, if symptoms persist, it can be repaired by surgery.

Who is at Risk of Getting a Varicocele?

• Approximately 15% of general male population have varicocele.

• The percentage increases to 40% in infertile men.

• The chances of developing varicocele are higher in the age group 15-35 yrs.

What are the symptoms of Varicocele?

You may or may not notice varicoceles as it often produces no signs or symptoms. You might experience -

• Lump in one of your testicle (mostly left side)

• Swollen scortum

• Dull discomfort to very sharp pain in your scortum

• You may notice your scortum is looking like a bag of worms because of the enlarged veins.

What can cause varicoceles?

Several causes of varicoceles have been suggested. Incompetent or absent valves within the gonadal or spermatic veins may lead to pooling of blood and the abnormal enlargement in the pampiniform plexus of veins. Additionally, the angle at which the gonadal vein enters the renal (kidney) vein may produce relatively high pressure within this venous system, leading to the swelling (dilation) of the pampiniform plexus. This explains why varicoceles are more common on the left side since the gonadal vein on the left side enters the renal vein. The right gonadal vein is not as long and does not join with the right venal vein. Rarely, enlarged lymph nodes or other abnormal masses in the retroperitoneum (the space behind the abdominal cavity) will block the gonadal veins, leading to increased pampiniform venous pressure and varicocele formation. This mechanism is only of concern when one develops a new varicocele.

How common are varicoceles?

Varicoceles are present in an estimated 15 percent of all men, whereas approximately 40 percent of men undergoing evaluation for infertility are diagnosed with this condition. No racial or ethnic groups are known to be at higher risk for development of a varicocele.

What are the symptoms of varicoceles?

Most men diagnosed with a varicocele have no symptoms, but varicoceles are important for several reasons. Varicoceles are thought to cause infertility and testicular atrophy (shrinkage). Approximately 40 percent of cases of primary male infertility and 80 percent of cases of secondary male infertility are believed to be due to varicoceles. Varicoceles rarely cause pain. When pain is present, it can vary from a dull, heavy discomfort to a sharp pain. The associated symptoms may increase with sitting, standing or physical exertion - particularly if any one of these activities occurs over long periods of time. Symptoms often progress over the course of the day, and they are typically relieved when the patient lies on his back, allowing improved drainage of the veins of the pampiniform plexus.

How are varicoceles diagnosed?

Large varicoceles can be discovered through self-examination. They may look or feel like a mass in the scrotum, and they have been described as having a "bag of worms" both because of their appearance and the way they feel. Asymptomatic varicoceles are often diagnosed on physical examination at the time of routine medical evaluation. Physicians typically diagnose varicoceles with the patient in the standing position. The patient may be asked to take in a deep breath, hold it, and bear down while the physician feels the scrotum above the testicle. This technique, known as the Valsalva maneuver, assists the physician in detecting abnormal enlargement or increased fullness of the pampiniform plexus of veins. A physician may order a scrotal ultrasound test to help make the diagnosis, particularly if the physical examination is difficult or inconclusive. Radiographic hallmarks of varicoceles on scrotal ultrasonography are veins greater than three millimeters in size with reversal of blood flow within the veins of the pampiniform plexus during the Valsalva maneuver. However, most varicoceles are diagnosed in most patients on the basis of physical examination alone. Most physicians do not believe that ultrasonography should be utilized to identify small or subclinical varicoceles since several studies have shown that "subclinical" varicoceles - those detected on the basis of ultrasound or other radiographic study alone - are usually not clinically relevant. Thus, routine radiographic screening for varicoceles in the absence of physical findings is not encouraged.

What are the treatment options for varicoceles?

Treatment of varicoceles is an appropriate consideration in some patients with infertility, pain or testicular atrophy. No medical therapies are available for either treatment or prevention; however analgesic agents may alleviate associated pain when present.

There are two main approaches to the treatment of a varicocele:

Surgical Repair: This approach involves a variety of specific techniques, but all involve ligation (obstructing) the spermatic or gonadal veins thus interrupting blood flow in the vessels of the pampiniform plexus. The surgical approaches include open surgical repairs performed through a single incision with or without the use of optical magnification (e.g., magnifying glasses or loupes or an operating microscope). Laparoscopic varicocele repair which utilizes telescopes passed through the abdominal wall are not generally used since they are thought by most to have greater potential for serious complications than standard surgical techniques without significant advantage. The open procedures are performed under a variety of anesthetics, from local to general anesthesia, whereas the laparoscopic approach is uniformly performed under a general anesthetic agent. With the advent of smaller incisions, which avoid muscle transection, the open procedures are becoming closer to the laparoscopic techniques in both speed of recovery and postoperative pain. Complications resulting from either open or laparoscopic approaches are rare, but include varicocele persistence/recurrence, hydrocele formation and injury to the testicular artery.

Percutaneous Embolization: This procedure is performed by radiologists using a special tube that is inserted into a vein in either the groin or neck. After radiographic visualization of the enlarged veins of the pampiniform plexus, coils or balloons are released to create an obstruction (blockage) in the veins. This obstruction then typically leads to interruption of blood flow within the pampiniform plexus vessels and disappearance of the varicocele. Percutaneous embolization is typically performed with intravenous sedation anesthesia and usually takes several hours to complete. Complications may include varicocele persistence/recurrence, coil migration and complications at the venous access site. This has not been widely employed in most centers.

What can be expected after treatment?

Recovery time after surgical repair is usually rapid. Pain is usually mild, and patients are asked to avoid strenuous activity for 10 to 14 days. Office work can typically be done one to two days after surgery. A follow-up visit with the urologist is scheduled. A follow-up semen analysis is obtained three to four months later if the procedure was performed to treat associated infertility. Open procedures performed with optical magnification have a low recurrence rate of approximately one percent.

Recovery time after embolization is also relatively short. Again, pain is typically mild, and patients are asked to avoid strenuous physical activity for seven to 10 days after the procedure. Patients may return to office work one to two days postoperatively. The recurrence rate with embolization is generally thought to be higher than that achievable with optical magnification. Nevertheless, there are circumstances when embolization may be preferable.

The impact of varicocele correction on fertility is not entirely clear. Some studies demonstrate improvement in fertility after varicocele repair, while other studies fail to document this change. Semen quality is improved in approximately 60 percent of infertile men undergoing correction of a varicocele, and this treatment should be considered in the context of other available treatment options as couples pursue therapy.

Frequently asked questions:

What will happen if I choose to observe my varicocele, rather than undergo treatment?

Failure to treat a varicocele may result in testicular atrophy and/or a decline in semen quality. This may lead to infertility. The varicocele may, over time, lead to permanent, irreversible testicular injury.

I have pain with my varicocele. What can I do to help alleviate the pain?

The use of adequate scrotal support (e.g., athletic supporter, briefs style underwear, etc.) can help the pain associated with a varicocele. Lying on your back facilitates varicocele drainage and often improves episodic discomfort as well. Use of analgesic agents (e.g., acetaminophen, ibuprofen, etc.) may be of benefit in treating the pain associated with a varicocele. Additionally, many patients obtain lasting relief of symptoms with varicocele correction through the above-mentioned techniques.

I am considering having my varicocele corrected for fertility reasons. How long will I have to wait to see improvement in semen parameters?

Semen analyses are typically obtained at three to four month intervals after the procedure. Improvement is often seen within six months, but may not be observed until one year postoperatively.

My adolescent son was recently diagnosed with a varicocele. Should this be corrected?

Indications for correction of a varicocele in an adolescent include disparity in testicular size, with the affected side measuring greater than 2 cm3 less in volume than the unaffected side. Additionally, correction is a consideration in patients with pain. Treatment of adolescents is highly individualized, and consultation with a urologist to further discuss the appropriateness of treatment for a particular patient is highly recommended. Often patients or families will choose to repair varicoceles to minimize the potential risk for future fertility or minimize the concerns about this complication.

I am interested in fertility and have no symptoms. Should I have my varicocele repaired?

Generally, asymptomatic varicoceles are not repaired. Most physicians do not believe there are health consequences of untreated asymptomatic varicoceles.