Index
The scrotum is a sac-like structure; it is covered with skin and supports the testicles.
The scrotum contains the arteries and veins that carry blood to the reproductive glands.
An abnormality in the scrotal vein can cause a varicocele.
A varicocele is a varicose dilation ( varicose veins ) of the veins of the spermatic cord, which are located in the bursa above and around each testicle.
This dilation results from a malfunction of the valves located in the veins.
Blood can no longer ascend through the veins to join the more prominent veins (left renal vein and inferior vena cava).
15% of the male population and 4 out of 10 men who consult for subfertility or infertility will be affected by varicocele.
Below ten years, cases are sporadic. However, after 19 years, the chances are more and more frequent.
The disease generally occurs between 15 and 25 years of age and is estimated to occur in 15% of men. Still, it should be noted that, with the introduction of more sophisticated research medical methods, the percentage in question increases until it touches 35%.
In most cases, it is a left varicocele, which affects the left testicle. However, the disease can also affect the right testicle or testicular varicocele.
And it can also affect both. In the latter case, we are talking about bilateral varicocele.
Varicoceles are a common cause of infertility due to no sperm production and decreased sperm quality.
Varicoceles can also cause the testicles to shrink.
The testicle is smaller on the side where the veins are dilated.
Very little is known about the female varicocele, but this disorder is not an exclusive problem for men; it can also affect women.
When the varicocele is female, it affects regular sexual activity. This is a disorder with characteristics very similar to those of men.
In particular, there is a failure in the area of the uterus and ovary in women.
The expansion of a vein in the female genital tract causes the appearance in women of varicocele or pelvic varicocele.
Varicoceles, most of the time, develop over time.
Favorably, varicoceles are mostly very easy to diagnose, and many do not even require treatment.
When a varicocele causes bothersome symptoms, it can often be corrected surgically.
Varicocele, causes of the disease
The disease is known to be caused by the fact that in some people, the spermatic cord that carries blood to and from the testicles malfunctions and prevents testicular blood from the scrotum from being sent back to the heart.
The weakness of the vein walls determines the malfunction of the valve system in question.
It is not sure what causes varicoceles, but many experts think of some forms of varicocele when valves within the marrow veins prevent blood from flowing properly, causing the veins to expand (dilate).
In most cases, primary varicocele is a disease of idiopathic origin. It is likely that behind the onset of the disease, there are morphological factors that determine a chronic weakness of the venous walls.
The varicocele is located in most cases in the left testicle due to the particular male anatomy: the position of the left testicular vein.
If it is a right testicular varicocele, diseases that affect the body region or the back of the peritoneal pelvis may need to be treated.
Varicocele can also occur as a result of gonadotropin therapy.
Varicoceles often form during puberty. However, a varicocele in one testicle can affect sperm production in both testicles.
In the female varicocele, the causes are not defined, but they have something to do with pregnancy and hormonal dysfunction.
Risk factor’s
There appear to be no significant risk factors for developing a varicocele. However, some research suggests that being overweight can increase your risk.
Varicocele symptoms
There are no specific symptoms of varicocele.
The disease is generally known to be asymptomatic.
The most common symptomatic manifestations consist of a feeling of heaviness and mild pain that affects the scrotal area.
The symptoms become more intense if you are in one position for a long time due to particularly intense physical exertion.
Visibly enlarged veins are often described as a bag of worms in the scrotum, manifesting as a vermicular skein.
Varicocele can be subclinical, when it is not visible or palpable, first-degree varicocele, mild level, second-degree varicocele, which is not seen but is palpable, third-degree varicocele, which is more severe and visible and tangible.
Varicocele can occur in an entirely asymptomatic environment, causing a series of testicular lesions over time but without triggering symptoms or warning signs.
The percentage of men go to diagnostic varicocele for other reasons, which can increase after sex.
Some men may experience pain, which may increase when standing or straining, worsen throughout the day, or get better when they lie down.
Varicoceles can get larger over time and become more noticeable.
Other potential symptoms may include a lump in a testicle, swelling in the scrotum, or visibly enlarged or twisted veins in the scrotum.
In women, the discomfort tends to be even more unbearable; during the menstrual cycle, a stinging and throbbing pain can endanger the quality of life of the affected women.
It is often confused with symptoms of other more common women’s diseases, and therefore it is likely to be the diagnosis of delayed varicocele.
Consequences of varicocele
The consequences of varicocele are represented by the fact that the downward flow of blood determines a situation of Hypertension in the veins.
With time, the latter expands and lengthens, undergoing a process of enlargement.
In addition to dilated veins, the testicular temperature rises, and exposure to the risk of infertility.
In addition, varicocele can also affect sperm production, leading to “testicular atrophy.”
Varicoceles and fertility
Although varicoceles may not cause any painful symptoms in some men, they can be a significant cause of infertility.
Sperm are produced in the testes, which are found in the scrotum.
For optimal sperm production, the testes should be slightly more remarkable than the typical body temperature.
However, when there is a varicocele, the extra blood in the veins warms the testicles and reduces sperm production.
Diagnosis of a varicocele
Varicocele, an enlarged vein in the scrotum, can be easily diagnosed through a physical exam.
As the vein enlarges over time, it becomes more apparent and can be easily felt by the doctor.
When your doctor performs a physical exam, and you feel a non-sensitive mass in your scrotum that feels like a bag of worms, you likely have a varicocele.
In this physical exam, the testicles are examined when the patient is standing and lying down.
If the varicocele is small, the doctor will be able to detect the abnormal size of the vein by asking the patient to stand up, take a deep breath, and hold their breath while palpating the scrotal area.
If the physical examination is inconclusive, or when a varicocele is not readily visible, the urologist will recommend that the patient undergo a scrotal ultrasound; abnormal blood flow can be detected by non-invasive imaging tests.
The doctor may require a scrotal ultrasound to evaluate and measure the spermatic veins and obtain an accurate and detailed image of the scrotum and dilated veins.
This imaging test involves high-frequency sound waves that produce images of the structures within the scrotum and can also be used to confirm if there is no other underlying reason behind your symptoms.
Treatment
The main goal of surgical procedures for varicocele is to seal off the enlarged vein to redirect blood flow to other healthy veins.
Varicoceles cannot be treated with oral medications.
However, if your varicoceles are not affecting your testicular function and want to control pain or discomfort eventually, you can take over-the-counter pain relievers such as ibuprofen or acetaminophen.
Varicocele treatment consists of different types of interventions on the varicocele.
You can resort to transfemoral embolization, scrotal sclerotherapy, surgical ligation of the spermatic veins, microsurgery, or laparoscopic ligation.
Transfemoral embolization is not a very invasive surgical technique like scrotal sclerotherapy.
Surgical spermatic vein ligation has been used mainly in the past, and the patient must be admitted to the hospital for a day or two.
This percutaneous embolization is not a widely used surgical procedure for varicocele treatment.
In this procedure, the specialist implants a tube in a vein located in the groin or neck.
The doctor will be able to see the varicoceles on a monitor and may release coils or a solution that heals and blocks the enlarged veins.
Normal blood flow is disrupted, and varicoceles will be repaired.
After embolization, the patient can return to their daily tasks after two days and even begin strenuous activities, such as exercise.
Microsurgical ligation is performed under local anesthesia and requires hospitalization for a few hours.
Laparoscopic site ligation is generally established for the treatment of bilateral varicocele.
Varicocele operation, in general, can have positive results in 90% of cases and generally does not show serious complications.
Open surgery is usually performed on an outpatient basis. Under general or local anesthesia, the surgeon will access the enlarged vein through the groin or an incision under the groin or in the abdomen.
Due to the advancement in varicocele operations, such as the operating microscope to allow the surgeon to see the area better and ultrasound.
A Doppler can guide the procedure, and postoperative complications are significantly reduced.
After open surgery, the patient can return to normal activities, except strenuous ones.
After two weeks, the patient can return to more strenuous activities if they do not feel uncomfortable.
While the pain from this procedure is mild, it can last for several days or weeks.
To decrease pain, your doctor may prescribe pain relief medications for a time after the procedure and recommend that you take over-the-counter pain relievers, such as ibuprofen or acetaminophen, to ease the discomfort.
You may also be advised not to have sex for a certain period.
Regarding sperm quality and sperm production, positive changes will only be seen through semen analysis several months after the procedure is performed.
This is because it takes around three months for new sperm to be produced.
After the surgery is done, the doctor will likely recommend that the patient wear a scrotal support and use a cold compress on the area to reduce swelling.
Compared to other surgical procedures, open surgery performed with a microscope and the subinguinal approach, microsurgical subinguinal varicocelectomy, is the most effective and has a higher success rate.
