Varicoceles

 

Background

Causes

Diagnosis & Evaluation

Treatment

On the Web

 

Background

Every structure in the body requires blood flow - inflow of fresh blood through arteries and outflow of blood through veins. The testes are no different - in fact, there are 5 recognized venous drainage systems from the testicles:

  1. Gonadal (testicular) vein: these are the longest and drain up near the kidneys
  2. Deferential (vasal) veins: travel with the vas deferens
  3. Cremasteric: these terminate in the inferior epigastric veins
  4. Gubernacular: drain to the superficial scrotal system
  5. Sub-inguinal collaterals: drain to the superficial system

The venous drainage system is quite complex and forms 'heat exchange system' which helps keep the operating temperature of the testis below that of the core body temperature - sperm production works best when the temperature is a little lower. The blood returning from the testis in the veins cools the blood entering the testis in the arteries. The heat exchange system forms the pampiniform plexus. The gonadal, deferential and cremasteric veins all contribute with the gonadal vein being the main contributor - it also happens to be the longest vein and most prone to cause a varicocele.

 

Everyone has veins in the scrotum they always contain blood leaving the testicles. When the veins forming the pampiniform plexus are larger then usual they are called varicoceles - very similar to varicose veins that occur in the legs. Varicoceles are very common - occurring in about 1 in every 7 males - approximately 450 million men on earth have a varicocele. Obviously, not all men with varicoceles have difficulty conceiving and most men with varicoceles are able to father children.

 

In some circumstances, however, the pooling of blood in the pampiniform plexus can result in impairment of sperm production by overheating the testis. One of the reasons the testes hang outside of the body in the scrotum is to keep testicular temperature below core body temperature.

 

Causes

Most varicoceles are idiopathic - meaning that a specificcause is not identified. In most man, a varicocele is simply a normal anatomical variation. Several different hypotheses for why varicoceles or more common on the left than on the right had been put forward including differences in the anatomy of the LEFT versus the RIGHT gonadal vein. The LEFT vein is longer, inserts into the renal vein which passes under the superior mesenteric artery. The finding of an isolated RIGHT gonadal vein is somewhat unusual and in slight population is an ultrasound to exclude obstruction of the LEFT gonadal vein by a mass.

 

Diagnosis & Evaulation

 

Varicoceles can be classified based on physical examination (Clinical) or based on ultrasound. Physical examination is usually more sensitive and relevant than ultrasound for diagnosis and classification.

Clinical Ultrasound

Grade I (small): palpable with valsalva only

Grade II (moderate): palpable standing w/o valsalva

Grade III (large): visible

Small: 2-3.4 mm

Medium: 3.5-4.9 mm

Large: ≥5 mm

Treatment

 

Varicoceles are about 4x more common in men having difficulty conceiving than those without problems. The primary issue when a varicocele is identified is determining if correction of the varicocele will increase the probability of obtaining a pregnancy. Note that the goal of varicocele correction is to improve the chances of attaining a pregnancy, not simply improving the semen analysis parameters. Only a select subgroup of couples with infertility will benefit from correction of a varicocele in the male. Your urologist will discuss the utility of repairing the varicocele with you.

 

In general, all of the following criteria should be met before considering varicocele correction

  1. Infertility: Difficulty obtaining a pregnancy after 1 year of trying
  2. Low numbers of sperm: Oligospermia - sperm concentrations less than 20 million per ml
  3. Larger varicocele: generally defined as a Grade 2 or greater varicocele

Virtually all studies show that in the absence of these criteria, correction of a varicocele is unlikely to make any difference in the chances of obtaining a pregnancy.

 

There are other reasons to repair varicoceles but these are less common than the reasons stated above. Other reasons for varicocele correction include:

 

  1. Symptoms. Varicocele-related pain is uncommon and therefore pain in the scrotum should not routinely be attributed to a varicocele if one is present. Other causes should be excluded. Most studies demonstrate that varicocele-related pain only occurs in men with large varicoceles (grade 3) and that repair is unlikely to help unless the pain is worse with prolonged standing and is a 'dull ache'.
  2. Preservation of future fertility. Adolescents may present with varicoceles. While they may not actively be attempting to achieve a pregnancy, preservation of fertility is important. Consideration to repair should be given to teenages with varicoceles grade 2 or larger associated with a significant discrepancy in testicular volume or consistency. The fact that there may be a normal discrepancy in testicular volume and consistency as a male progresses through puberty can make a decision difficult. In such cases, repeated examination every 6-12 months is warranted.

 

Mangement Options

 

If you have a varicocele and are not having any problems, they can usually just be left alone. If you meet criteria for correction, there are 2 primary options for repair:

  1. Surgery: subinguinal microscopic varicocelectomy
  2. Embolization: a procedure performed by a radiologist to block the gonadal vein

There are pros and cons to each. In general, a surgery is the most effective way to repair a varicocele because not only can it correct the veins that are the major contributors to the varicocele (the gonadal and cremasteric veins) but also can address the collateral veins to the superficial system (the gubernacular and subinguinal veins). Note that the deferential vein is left intact so that venous drainage from the testis is preserved.

 

Embolization only addresses the gondal vein so the success rates are usually a little lower. Having said that, since the gonadal veins are the main contributing factor to a varicocele, embolization will correct a majority of varicoceles. The trade off for a higher success rate for surgery is a longer recovery time (weeks rather than days). In some circumstances, surgery will provide a much higher success rate - especially if you have a very, very large varicocele - and can also be used if an embolization fails. 

 

While complications are rare, both procedures can be associated with the development of fluid collections (hydroceles or lymphoceles), bleeding and pain. Embolization requires the use of intravenous contrast which can cause a reaction; the venipuncture in the neck may cause problems and the coils/'superglue' used to block off the veins may migrate and are permanent. Surgery can be associated with infection in rare cases.

 

Both of these approaches require subspecialized training for optimal results - either in male infertility or interventional radiology. Fortunately, there are a couple of urologists in the Greater Vancouver area with subspecialty training as well as certain radiologists who have a incredible amount of experience in varicocele embolization.

 

Aftercare

After your varicocele is treated, follow-up is required. In general:

  1. Physical examination and follow-up ultrasound to ensure satisfactory treatment
  2. Semen analysis to check for improvement in parameters. Usually done every 3 months or so following treatment until a pregnancy is achieved

 

 

On the Web

General Urology Web Sites

AUA patient information brochure on varicoceles

 

Author(s): K Poon  Major Revision/Review: June 2016