Varicocele

A varicocele - note the dilated tortuous veins.

A varicocele is an abnormal enlargement of the veins of the testicles. This can be quite disfiguring and cause symptoms such as pain & discomfort or even infertility.

Varicoceles are usually first noticed in patients between the ages of 15-35. They are common, affecting 8-20% of the general male population, and around 40% of subfertile men. The majority of varicoceles tend to occur in the left testicle. This is due to a number of anatomical differences between the left and right testes.

Around the testicles are a network of veins which drain it, called the pampiniform plexus. The veins contain valves in order to assist in returning blood back to the heart. However, these valves may become incompetent or malfunctioning. (This mechanism is also responsible for varicose veins in the legs.) As a result, the blood in the veins tends to pool around the testes. This can lead to increased pressures & temperatures in the testicles and may lead to tissue damage.

It is the pooling of blood in the veins of the testicles which is responsible for the various symptoms of varicoceles:

• heaviness or a dragging sensation in the testicles
• scrotal pain
• testicular atrophy (shrinking of the testicles)
• infertility
• poor cosmetic appearance - enlarged bluish testicle

The infertility is thought to be due to problems with temperature regulation of the testicles. The testicles should ideally be 2-3 degrees below the body temperature for optimal production of sperm. It is thought that pooling of the testicular blood may raise the temperature of the testicles, impeding sperm production. More evidence is required to determine whether treatment of varicoceles can improve fertility. Varicoceles can usually be diagnosed from a clinical history and examination of the testicles. Varicoceles may be plainly visible on inspection or able to be felt on examination. Small varicoceles may only be identified on bearing down.

There are currently no effective drug treatments for varicoceles. The mainstay of treatment is surgery. The abnormal veins are tied off in a process called ligation. There are a number of ways for surgeons to get at the testicular veins, including a direct open approach and laparoscopically. Treatment is usually effective in relieving the symptoms, and improving the production of sperm.

Interventional radiology offers a minimally invasive treatment of varicoceles known as varicocele embolisation. The aim is to cause the abnormal veins to become completely occluded so that blood can no longer pool in those areas. Embolisation can be done with metal coils or special embolic agents - these are substances that solidify on contact with blood and are impermeable. Varicocele embolisation is very effective, as shown by improvements in sperm quality and pregnancy rates after the procedure. It has the added benefit of being quick (most patients may go home within 2 hours of the procedure) and having a faster recovery time compared to surgery. Complications of the procedure are rare, but usually amenable to simple treatments.

This varicocele was treated using an embolic agent. Note the dilated veins on the before image. The black arrows point to the site of the varicocele. After treatment, there is no further flow into the veins.

Links

Patient UK - Varicocele
Australian Doctor - Varicocele Patient Information pdf