Varicocele

What is a varicocele?

The term comes from Latin and Greek origins (in Latin, varix means "varicose vein" and in Greek, kele means "hernia") and refers to an enlargement of the veins in the testicles (known as the pampiniform plexus). The varicocele is often visible through the skin. When standing, they may cause swelling in the testicle along with a feeling of heaviness.

A varicocele affects up to 20% of men in Germany, with about 8% experiencing it in both testicles. Its occurrence becomes more common with age.

What causes a varicocele?

The causes of varicoceles are similar to the causes of varicose veins in the leg. We differentiate between primary and secondary types.

Primary varicoceles occur when the veins enlarge due to blood pooling caused by weak venous valves. This is more common on the left testicle, as the pressure in the draining vein is higher on that side due to the positioning of the blood vessels. Growth spurts and increased pressure during puberty can also contribute to the development of a varicocele.

Secondary or symptomatic varicoceles are typically caused by obstructions such as tumors or a blockage in the vessels (e.g., thrombosis) resulting from other conditions.

How do you recognize a varicocele?

A varicocele is first noticeable as a painless, and usually unilateral enlargement of the testicle, which can cause pain or discomfort as it increases in size. A primary varicocele can be distinguished from a secondary varicocele in that the swelling decreases when lying down, whereas in a secondary varicocele it stays the same.

The testicles are examined by visual inspection and palpation while standing and lying down. An ultrasound examination of the blood vessels can lead to a definitive diagnosis. If vascular abnormalities are suspected, for example a recurring varicocele, an examination of the veins (phlebography) can also be carried out.

If a secondary varicocele is suspected, then a tumor investigation by means of a CT or MRI scan of the trunk is required to rule out malignant disease as the cause.

What effects do varicoceles have on family planning?

Varicoceles are found somewhat more frequently in infertile men compared to fertile men. It has not been conclusively determined whether varicoceles actually impair fertility. However, it is plausible that they do, as the blood pooling in the testicle increases the temperature. For optimal sperm production, the temperature should ideally be 2°C below body temperature, which is why the testicles are located outside the abdominal cavity.

How is a varicocele treated?

In most cases, a primary varicocele does not require treatment. If treatment is indicated (see below), the goal is to interrupt the venous reflux. This can be achieved through open surgery, laparoscopic procedures, microsurgery, or angiographic methods, i.e., accessing the blood vessels via the groin. In these procedures, the vein (testicular vein) is either clamped and severed or internally sealed.

Treatment of a secondary varicocele involves addressing the underlying cause, such as dissolving a blood clot or surgically removing a tumor. Once the cause is treated, the varicocele typically resolves on its own.

When is a varicocele surgery appropriate?

In most cases, a varicocele does not require treatment. The following reasons may indicate the need for therapy:

• Pain
• Infertility (if suspected, a sperm analysis (spermiogram) can be performed)
• Cosmetic concerns
• Significant findings in childhood

What is the procedure for varicocele surgery?

The procedure depends on the method chosen. Angiographic techniques can be performed on an outpatient basis under local anesthesia. For other therapies, general anesthesia is used. An incision may be made in the groin, above it (similar to an appendectomy), or directly on the testicle. Alternatively, three small incisions may be made to insert instruments for laparoscopy, allowing access to the affected vein. The spermatic duct and artery are preserved, and the vein is either severed or sealed by injecting a sclerosing agent.

What is the course and prognosis of the condition?

Pain or cosmetic issues may develop over time with a present varicocele. It could potentially also impair fertility. However, varicoceles often remain asymptomatic.

If surgery is performed, the varicocele persists in 29% of cases. Other potential risks of the procedure include hydrocele (fluid accumulation around the testicle) and testicular atrophy (shrinkage). The risk of these complications is lowest with microsurgical techniques.

Can varicoceles be prevented?

There are no known effective methods to prevent varicoceles.

Which doctors and clinics specialize in treating varicoceles?

Varicoceles are a urological condition. The diagnosis can also be made by a general practitioner. If the diagnosis is unclear or surgery is recommended, a referral to a urological practice or clinic is made.

Author:

• PRIMO MEDICO Editorial team| Created on 12.02.2018 | Last updated on 06.03.2020

Sources:

• Hautmann, R. (2010): Urologie, 4.Aufl. Springer, Heidelberg

• Der Urologe. Band: 53, Nummer: 2, 2014, doi

• Meier, John: Varikozele: Klinik und Therapie. In: Journal für Urologie und Urogynäkologie. 2013