Prof Saim Yılmaz, MD
"Most varicoceles can be nonsurgically
treated with embolization"
Varicocele is a group of varicose veins that occur around the testicle.
Color Doopler ultrasound is the most practical method in both diagnosis and staging of varicocele.
With venography, the refluxing veins that cause varicocele can be easily identified and treated in the same session.
WHAT IS VARICOCELE?
Varicocele is a group of varicose veins that occur around the testicle. It is seen in about 10% of young men and generally diagnosed between 15-30 years of age.Varicocele occurs as a result of venous insufficiency of the main testicular vein (internal spermatic vein). Normally, the venous blood is collected via a network of small veins around the testicle and flows upward towards the lungs. The one-way walves in the main testicular vein are the key factor for this flow, which is against the gravity. However, these walves may lose their function by time in some men due to a number of reasons, and the venous blood starts to flow back towards the testicle. This backflow (reflux) increases the blood pressure in the tiny veins around the testicle and causes them to enlarge and become what we call “varicocele”.
What are the signs of varicocele?
In some men, varicocele does not cause any symptoms. If the sperm number and quality are normal treatment may not be required in such cases. In some however, varicocele may cause important problems including infertility. The most common symptoms of varicocele are as follows:
1. Pain: In patients with varicocele, pain may occur because of the increased blood pressure in the veins around the testicle.
2. Infertility: The blood accumulated in the testicular veins may increase the temperature in the testicle. This may decrease the sperm count and mobility and cause sperm deformation by time. In one study, about 40% of the infertile men were found to have varicocele. In 50-70% of such cases, correction of the varicocele with embolization or surgery may result in improvement of sperm parameters.
3. Atrophy: In varicocele, retention of the deoxygenated venous blood in the testicular veins may impair the blood circulation and cause testicular atrophy (shrinkage). If the patient is diagnosed at an early stage and treated properly, the testicle may regrow and reach its normal size.
4. Bad appearance: Some varicoceles may be large enough to be readily seen when the patient is standing. This may disturb some patients and cause psycological problems.
5. Leg varicosities: In some patients, varicocele may be accompanied by leg varicosities. Likewise, in patients with leg varicosities a varicocele may be detected just by coincidence. In such patients, both the varicocele and leg varicosities may be caused by the insufficiency of the main testicular vein, and the occlusion of this vein may not only treat the varicocele but also be beneficial for the leg varicosities.
How it is diagnosed?
Large varicoceles may be felt by the patient or palpated by the doctor during manual examination. If the varicocele is not large it can be overlooked during the manual examination. Such varicoceles can be easily seen with color Doppler ultrasound. The color Doppler ultrasound may also demonstrate the reflux (backflow) into the testicular veins and helps staging of the disease based on the amount of reflux and diameter of the testicular veins.
Another method of diagnosing varicocele is venography. For this, the patient is put on the angiography table and the vein is punctured at the groin or armpit under ultrasound guidance. Then, a tiny tube called catheter is advanced into the main testicular vein and serial X-ray films are taken while a small amount of contrast (dye) is injected through the catheter. The patient is also asked to perform a Valsalva maneuver (taking a deep breath and strain) to increase the abdominal pressure and provoke venous reflux. In patients with varicocele, the contrast flows back towards the testicle and this can be easily seen on venography. Thus, with venography, the presence or absence of reflux can be seen as easily as color Doppler ultrasound. But more importantly, the refluxing vein(s) that cause varicocele can also be readily identified, while color Doppler ultrasound can not show them. In fact, venography is the only method that can reliably demonstrate the incompetent veins which are the cause of the varicocele. Despite this, since it requires a venous catheterization, venography is not routinely used in the diagnosis of varicocele. Instead, it is a part of embolization procedure and used to identify the refluxing veins that will be closed during the embolization.
When should varicocele be treated?
In some patients, varicocele does not cause any symptoms and in these, treatment may not be necessary if the sperm parameters are normal or the patient does not want to have children. If the patient has symptoms such as pain and testicular atrophy, sperm parameters are abnormal or he wants to have children, then the varicocele must be treated. After successful treatment, the pain goes away because the blood pressure in the veins returns to normal. Sperm parameters may get better since the temperature of the testicle become normal and the small testicle may reach its normal size by time since the impaired blood circulation returns to normal. After treatment, it is expected that in half of the patients, the sperm parameters will improve and in about 40% their partners will become pregnant. However, even a perfect varicocele treatment may not guarantee a successful outcome; in some patients, sperm parameters may not improve after embolization or surgery and pregnancy may not occur. Despite that, if an infertile man has varicocele it is recommended to treat it with embolization or surgery before any further diagnostic and therapeutic procedures are started. Because, varicocele is the most easily treated cause of infertility.
If the patient has no complaints is varicocele still to be treated?
In such patients, surgical treatment is not recommended. This is widely because surgery may have important side effects that may compromise the quality of life and this risk may outweigh the potential benefits of the surgery in such asymptomatic patients with varicocele. In embolization however, the risks and side effects of the procedure are far less than surgery. It should also be remembered that varicocele is a venous circulation problem and may cause pain and infertility in the future.
For these reasons in our center, we routinely consider embolization in grade 2-3 varicocele patients even if they do not have any symptoms.
In some patients, varicocele and lower extremity varicose veins may coexist and both may occur due to the insufficiency of the main testicular vein. In these patients, a testicular venography should be performed and if there is reflux in the main testicular vein towards the testicle and leg, then this vein should be closed with embolization. In this way, both the varicocele and the cause of the leg varicosities can be treated in a single session.