What Is Varicocele?

Overview

Varicocele is a condition characterised  by the enlargement of veins in the scrotum, usually on the left side. The exact cause is not fully understood, but it is believed to be related to weak or damaged valves in the veins. Varicoceles are more common in adolescent males and young adults. While some individuals may not experience any symptoms, others may have pain, discomfort, swelling, or a lump in the scrotum. 

Varicoceles can be diagnosed through physical examination and confirmed using ultrasound or Doppler imaging. Treatment for varicoceles is not always necessary, especially if there are no symptoms or fertility issues. However, if treatment is required , options include observation, surgical procedures (varicocelectomy), or interventional radiology procedures (embolization) to block the abnormal veins. 

Varicoceles are generally considered to be benign (meaning that they are not cancerous), but they can  lead to complications such as testicular atrophy or impaired fertility, if left untreated. Consulting with a healthcare professional is recommended to determine the best course of action based on individual circumstances. 

Causes of varicocele

The exact causes of a varicocele is  not fully understood, but several factors are believed to contribute to its development.³ These include:

1. Abnormal vein valves: The veins in the scrotum have one-way valves that help regulate blood flow. If these valves weaken or become faulty, blood can pool and accumulate, leading to the enlargement of the veins and the formation of a varicocele

2. Venous insufficiency: Venous insufficiency refers to the impaired functioning of the veins, resulting in inadequate blood flow back to the heart. This condition may contribute to the development of a varicocele

3. Anatomic variations: Certain anatomical differences in the veins and blood vessels within the scrotum may increase the risk of a varicocele. These structural variations can disrupt normal blood flow and contribute to the dilation (enlargement) of veins

4. Genetic predisposition: Certain genetic factors may contribute to the susceptibility of developing varicocele

It is important to note that while these factors are commonly associated with varicoceles, not all individuals with a varicocele will have the same underlying causes. Varicoceles can also occur spontaneously without any clear identifiable cause.

Signs and symptoms of a varicocele

Some individuals with a varicocele may not experience any symptoms, while others may notice various signs and symptoms. Here are the common signs and symptoms associated with varicoceles:

1. Dull or aching pain: Varicoceles can cause mild to moderate pain or discomfort in the scrotum. The discomfort is frequently described as a dull, painful feeling that frequently subsides when you lie down
2. Testicular atrophy: It refers to the shrinking of the affected testicle(s). This can be accompanied by a noticeable difference in size between the testicles
3. Fertility issues: Varicoceles have been associated with impaired sperm quality and fertility problems
4. Visible Enlargement: Enlarged, twisted veins that can be seen or felt within the scrotum. Larger varicoceles may feel or appear like  spaghetti or a bag of worms. Smaller varicoceles could be difficult to see or feel

Management and treatment for varicocele

The management and treatment options for varicoceles depend on the severity of symptoms, potential fertility concerns, abnormal semen analysis, and individual preferences. Here are some common approaches:

Medication: There are currently no pharmaceutical treatments available to cure or prevent varicoceles. However, the use of pain relievers such as acetaminophen or ibuprofen can provide relief from any associated pain or discomfort.

Lifestyle modification: Lifestyle Modifications can be implemented such as  avoiding prolonged standing or sitting, wearing supportive underwear, and scrotal elevation.

Radiologic Intervention (embolization): Involves injecting contrast dye through a tube guided by X-rays to identify the root cause of the issue  (to locate and address all the veins connected to the varicocele). Coils, which can be inserted with or without a dehydrating drug called sclerosant, are utilised to obstruct the blood flow to the varicocele. 

This procedure is typically conducted with local anaesthesia or light sedation through a small incision in the groin or neck. The duration of the procedure usually ranges from 45 minutes to an hour. 

Potential complications of an embolization: 

•  Persistence or recurrence of the varicocele
•  Displacement of the coil
•   Risk of infection at the site of tube placement 

Surgical treatment: The goal of surgery is to block or redirect the abnormal blood flow in the affected veins, by either suturing or clamping the vein to close it off (called a ligation) thereby improving fertility and relieving any associated symptoms. Surgery is typically performed under general anaesthesia. The two commonly used procedures are as follows:

Microscopic varicocelectomy: The surgeon makes a small incision (around 1 cm) above the scrotum and the surgeon precisely ligates the small veins with the aid of a microscope 

Patients are normally able to go home the same day after the treatment, which typically takes 2 to 3 hours.

Laparoscopic varicocelectomy: The surgeon inserts thin tubes into the abdomen and ligates   the veins. 

This procedure takes only 30 to 40 minutes and most patients are able to return home the same day. 

Complications of surgery:

With the advancement of smaller incisions in muscular areas during open surgery, the healing time and pain experienced are comparable between microscopic and laparoscopic procedures. Although they are not common, complications with either type of surgery can include:

• Persistence or recurrence of the varicocele
• Formation of fluid around the testicle (hydrocele)
• Injury to the testicular artery
• Damage to the testicular artery (very rare) 

While it is rare, there is a possibility that surgery may not completely resolve the issue. Microscopic surgery generally has the lowest rate of persistence or recurrence of the varicocele compared to laparoscopic surgery.

Recovery: 

Post-treatment recovery is generally quick  and associated with mild discomfort for both surgical and embolization procedures.It is important to avoid strenuous physical activity for a period of 10 to 14 days after surgery and 7 to 10 days after an embolization.It is typically possible to return to work within 5 to 7 days after surgery and one to two days after an embolization.Follow-up appointments with a urologist are scheduled, and after  surgeries , a semen analysis is conducted three to four months later to address fertility issues. 

Diagnosis of a varicocele

The diagnosis of a varicocele typically involves a combination of medical history evaluation, physical examination, and sometimes additional diagnostic tests. Here is an overview of the common diagnostic methods used for varicocele:

1. Medical history evaluation: It includes a detailed medical history, including any symptoms experienced and relevant risk factors.

2. Physical Examination: The healthcare professional will perform a thorough examination of the scrotum while the patient is standing, as this allows for better visualisation  and palpation of any enlarged veins. They may ask the patient to perform a Valsalva manoeuvre (bearing down as if having a bowel movement) to increase venous pressure and enhance varicocele detection.²

3. Imaging Tests: Either to confirm the diagnosis or assess the severity of a varicocele. These tests may consist of:
   • Doppler Ultrasonography: Ultrasound is used  to  detect the sound of blood back flowing  (when blood leaks backwards instead of moving in a one way flow), via the valve
   • Thermography: This employs infrared sensing technology, and enables the detection of a varicocele by detecting heat-producing pockets produced by the pooled blood
   • Scintigraphy: It is used to evaluate the hemodynamics (how the blood flows through your blood vessels) in the veins and arteries of the scrotum
   • Venography: Venography involves injecting a contrast dye into the veins of the scrotum and taking X-ray images. It provides a detailed visualisation  of the varicocele and its associated veins, but it is less commonly used than ultrasound

It is important to consult with a healthcare professional, typically a urologist or a specialist in reproductive health, for an accurate diagnosis of varicoceles. They will determine the most appropriate diagnostic approach based on individual symptoms and circumstances. 

Risk factors

While the exact cause is not fully understood, several risk factors have been identified. The following are some typical risk factors for varicoceles:

1. Family History: Varicoceles are  more likely to occur if there is a family history of the condition or varicose veins
2. Age: Varicoceles are most commonly diagnosed in teenagers than in older men
3. Puberty: The hormonal changes that occur during puberty, including increased testosterone levels and rapid growth, may play a role in the development of varicoceles

It is important to note that the presence of these risk factors does not guarantee the development of varicoceles. Varicoceles can also occur without any identifiable risk factors. 

Complications

Despite being frequently asymptomatic, varicoceles can result in problems like:

1. Decreased fertility: Varicoceles can hinder sperm function and production, which may result in decreased fertility
2. Pain or discomfort 
3. Reduced testosterone production in the testis

As a result, treatment for varicoceles is typically not necessary unless there is specific concern related to these problems. In certain instances, varicoceles can result in azoospermia, which refers to the absence of sperm in the ejaculate.

Summary

Varicocele is a condition characterized by the enlargement of veins in the scrotum, commonly on the left side. It is caused by weak or damaged valves in the veins, leading to pooling of blood and vein enlargement. While some individuals may not have any symptoms, others may experience pain, discomfort, swelling, or a lump in the scrotum. Varicoceles can be diagnosed through physical examination and imaging tests. Treatment options include observation, surgery (varicocelectomy), or interventional radiology procedures (embolization) to block the abnormal veins. Varicoceles are generally benign but can lead to complications like testicular atrophy or fertility issues if left untreated. It is important to consult a healthcare professional for an accurate diagnosis and appropriate treatment based on individual circumstances.