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Pediatric – Varicoceles

The male reproductive system works in a considerably complex manner. It is responsible for producing, maturing, and delivering sperm. Sperm is made in the testicles and is transported via the genital duct system to the opening of the penis for ejaculation. Every part of the reproductive system is important for ideal male fertility.

Scrotal masses are seen as abnormal masses in the male reproductive system. Although these are often non-threatening in nature, at times these increase the risk of developing dangerous diseases as well. There are numerous tests and treatment procedures which are advised to be followed by health experts for prevention or treatment of such abnormalities.

Testicular cancer is one such disorder which affects the male reproductive system significantly. This requires immediate medical attention to prevent further complications from arising. Varicoceles are another type of abnormal mass which affect the male reproductive system considerably and also cause pain. Thus, it is highly advised to seek immediate medical attention in case any abnormal mass is discovered in the tract.

Continue reading below to understand more about this dangerous disorder:


What are Varicoceles?

Spermatic cord contains the vas deferens which is helpful to supply blood to the testicles and transport sperm from there to the urethra and penis. The spermatic cord passes through the inguinal canal and continues into the scrotum. The spermatic cord also contains the pampiniform plexus veins which are responsible for draining the used blood from the testicles. These veins are also meant to maintain the ideal temperature in the testicle to enable ideal sperm production. The veins work to cool the blood inside the testicular artery before it is passed on to the testicle, which is essential for ideal production of quality sperm.

Varicoceles, basically, are dilations (enlargements) in the pampiniform plexus veins inside the scrotum. These are similar to the varicose veins in the legs and form during puberty. These become enlarged and noticeable as time passes. Varicoceles in the left-hand side are more common than on the right-hand side.


What can cause Varicoceles?

There are several reasons for the development of Varicoceles. Under-developed valves or absent valves inside the spermatic or gonadal veins may cause the blood to accumulate and result in abnormal enlargement in the pampiniform plexus of the veins. Apart from this, the angle at which the gonadal veins are connected to the kidney (renal) veins is also held responsible for pressurizing the veins which leads to swelling (dilation) of the pampiniform plexus. This may explain as to why this condition is more commonly seen in the left-hand side as the gonadal veins from the left enter the renal veins. The renal vein on the right-hand side is not long enough to join with the right renal vein.

In rare cases, enlarged lymph nodes and other abnormal masses in the space behind the abdominal cavity (retroperitoneum) can block the gonadal veins, which leads to pressure on the pampiniform plexus veins and develop Varicoceles.


How common are Varicoceles?

According to various research studies, around 15% of all men develop Varicoceles. At the same time, almost 40% of men undergoing evaluation for infertility problems are affected by Varicoceles. This condition is not seen in any specific ethnic or racial group.


What are the symptoms of Varicoceles?

Mostly, men affected by Varicoceles do not exhibit noticeable symptoms. However, this condition results in severe fertility complications and also shrinks the testicles (testicular atrophy). Research has shown that almost 40% of primary male infertility and around 80% of secondary male infertility cases are due to Varicoceles. Pain may be mild ache to severe and sharp bouts of pain. Symptoms are known to become prominent when sitting, standing or performing physical activities. Symptoms are seen to get worse in the day but the patient gets considerable relief when they lie on their back, which improves the drainage from the pampiniform plexus.


How are Varicoceles diagnosed?

Self-examination often shows the development of Varicoceles. They may seem and feel like an abnormal mass in the scrotum.

Asymptomatic Varicoceles are mostly diagnosed with a physical examination during a regular medical test. The physician normally checks for Varicoceles while the patient is standing. The patient is asked to take a deep breath, hold it in and bend down slowly which allows the physician to check for abnormal mass in the pampiniform plexus veins of the testicle (Valsalva maneuver).

A scrotal ultrasound is also advised in case additional diagnosis is required. The doctor checks for veins that have grown over 3 mm in size and there is reversal of blood flow seen in the Pampiniform plexus.

Most physicians are of the opinion that physical examinations (such as Valsalva maneuver) are sufficient to diagnose the condition.


What are the treatment options for Varicoceles?

Although analgesic agents are helpful to relieve the pain which is caused by Varicoceles, there is no definite treatment or therapy which is useful for curing or preventing this condition.

There are two main types of methods used in this:


Surgical repair

In this, the surgeon performs a variety of surgical operations, mainly including ligation (obstruction) of the gonadal or spermatic veins which helps to interrupt the blood supply to the blood vessels in the pampiniform plexus. This requires making a small incision and is rarely performed using laparoscopic method due to the higher chances of complications arising from it. This procedure may involve administering local or general anesthesia, dependent on the surgeon’s decision.

As conventional open-type of surgical approach are using increasingly smaller incisions (similar to laparoscopic method), there has been a significant decrease in muscle transaction and increased improvement in recovery time and pain alleviation.

Risks, which are rarely seen, may include Varicocele recurrence or persistence, formation of hydroceles or injury to the testicular artery.


Percutaneous Embolization

This is a minimally invasive form of treatment. A radiologist inserts a special tube in the vein (groin or neck). This tube is guided using radiology equipment to the pampiniform plexus. The tube is attached in the front-end with a surgical balloon or coil, which is then deployed and inflated to create obstruction in the veins. This obstruction results in less blood flow in the pampiniform plexus blood vessels and eventually dissolves the Varicocele.

The surgeon/radiologist will administer intravenous anesthetic before starting this procedure.
Risks of this procedure may include coil/balloon displacement, recurrence or persistence of the Varicocele and other complications at the venous access site (incision)


What can be expected after treatment?

Recovery after surgical correction is usually faster than others. Pain is mostly mild in nature and the patient is advised to avoid strenuous physical activities for the first 10 to 14 days following the operation. The patient may however continue with desk work within 2 to 3 days after surgery. The patient is also advised for a follow-up visit to the urologist. Semen analysis is obtained within 3 to 4 months as well in case the procedure was aimed at correcting infertility problems.

Conventional surgical procedures (done by magnification methods) have a lower recurrence rate for Varicoceles.

In case of Embolization, the recovery time is also quite short. Pain is mostly mild in magnitude and the patient is advised to avoid physical activities for 7 to 10 days following this treatment. For patients who have a desk job, they can join work within 2 to 3 days mostly.  Comparatively, the recurrence rate is higher in this procedure.

However, certain conditions make this procedure beneficial as compared to other.

The effects of Varicoceles on fertility are not quite definitely known. Certain studies have shown that Varicoceles repair may have improvement in fertility while other studies have not been able to pinpoint this. Around 60% of operated Varicoceles cases have shown significant improvement in infertile men.


Frequently asked questions:

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

Avoiding treatment for Varicocele may result in complications, including testicular atrophy and/or decrease in semen quality which leads to infertility. This may eventually result in permanent and irreversible testicular injury.


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

Adequate supporting devices, such as scrotal supporters and brief-styled underwear can help to alleviate the pain to some extent in certain cases. Lying on the back is also known to provide temporary relief as well as it helps to drain the varicocele. Using analgesic agents also helps in improving the painful conditions.


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

Doctors normally advise semen analysis at intervals of 3 to 4 months following the treatment procedure. Significant improvement is noticed within the first 6 months. In some cases, improvement is often seen as late as after a year from the procedure.


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

Certain indicators that point to the need for correction of Varicocele in adolescent patients are the increase in the size of the affected testicle. The difference between the healthy and affected testicle size is between 2 to 3 cm. in addition, correction is considered in case of significant pain in the testicle.

The treatment for adolescents affected by Varicoceles is largerly dependent on the level of pain it is causing. Consultation with an experienced urologist is highly advised in such cases. Often times, the patient (or family) may decide to correct the condition to avoid or minimize the future complications which may arise due to it.


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

Normally, varicoceles that do not exhibit symptoms are not advised to be repaired as a majority of physicians do not believe that it affects overall health.

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