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Varicocele

A varicocele is a varicosity of the pampiniform venous plexus in the scrotum. Symptoms may include pain within scrotum and scrotal heaviness.


Presentation

Most varicoceles are asymptomatic; however, they may cause pain that varies from mild discomfort to a severe sharp pain. It is a dull, congestive, tooth-ache like pain and is not associated with urination problems or erectile dysfunction. Pain increases with standing and physical exertion over long periods of time and worsens over the course of a day. The pain is usually relieved by lying down.

When it enlarges, the varicocele can cause a clumpy “bag of worms” feel in the scrotum. Typically, painful varicoceles are prominent in size. A decreased sperm count, decreased motility of sperm and increase in the temperature due to varicoceles usually result in infertility in men. Testicular atrophy may also be seen in young boys at puberty.

Leg Edema
  • Affected patients usually present with unilateral leg edema. The condition is most often seen in women, in whom it may also be a cause of vulvar varicosities.[ncbi.nlm.nih.gov]
Respiratory Distress
  • Acute respiratory distress syndrome (ARDS) is a syndrome of acute respiratory failure that is associated with several clinical disorders including direct pulmonary injury and indirect pulmonary injury.[ncbi.nlm.nih.gov]
Vein Disorder
  • A varicose vein disorder can be a cause of male infertility but is fortunately, also the most surgically correctable.[malefertility.md]
Swelling of the Scrotum
  • A varicocele is swelling in the scrotum due to a backup of blood in the main veins of the testicles. It’s similar to having varicose veins in the legs.[sharecare.com]
  • However, if you experience pain or swelling in your scrotum, discover a mass on your scrotum, notice that your testicles are different sizes, or develop a varicocele in your youth, or you're having problems with fertility, contact your doctor.[mayoclinic.org]
  • […] in the scrotum.[medical-dictionary.thefreedictionary.com]
  • If symptoms do occur they may include: A dull ache in one or both testicles A dragging or heavy feeling in the scrotum Swelling in the scrotum (this is often described as feeling like "a bag of worms") The testicle on the side of the swelling is often[southerncross.co.nz]
  • This can cause swelling in the scrotum. Most varicoceles occur spontaneously due to incompetent valves in the veins. Most men with varicoceles generally have no symptoms. Some men do have a sensation of fullness or an ache in the scrotum.[lomalindafertility.com]
Scrotal Mass
  • ‘Other benign conditions resulting in a scrotal mass, such as testicular torsion, spermatocele, varicocele, or tuberculosis, must be ruled out.’ ‘Scrotal ultrasonography is helpful in confirming a varicocele or testicular tumour.’[en.oxforddictionaries.com]
  • If symptomatic, presentations include: scrotal mass /swelling scrotal pain testicular atrophy infertility or subfertility The pampiniform veins normally act as heat exchangers, important in the thermoregulation of the testes which is vital for spermatogenesis[radiopaedia.org]
Testicular Swelling
  • We describe the sonographic and colour Doppler appearances of this poorly described entity in a middle-aged man referred for evaluation of a painful left testicular swelling.[ncbi.nlm.nih.gov]
Microscopic Hematuria
  • The diagnosis was eventually made when he returned with microscopic hematuria, elevated serum creatinine level, and nonfunction of the left kidney; computed tomography scan demonstrated a 6-cm abdominal aortic aneurysm, a retroaortic left renal vein,[ncbi.nlm.nih.gov]

Workup

The gold standard way to diagnose varicocele is by physical examination. About 95 percent of varicoceles are found on the left side of the scrotum. The general physical examination of a patient in standing position reveal a tender, non twisted mass above the testicle.

If large enough, it can be felt as a bag of worms. If a varicocele is small, it can be felt by asking the patient to take a deep breath and hold it (Valsalva maneuver). The testicles may be shrunken in size.

During palpation, a varicocele must be differentiated from the lipoma of the cord. Unlike a varicocele, a lipoma will not go away when the patient lies down.

A noninvasive imaging exam called color flow ultrasound or a venogram can often be used to detect a varicocele, if not diagnosed through the physical examination.

Sperm Count Decreased
  • A decreased sperm count, decreased motility of sperm and increase in the temperature due to varicoceles usually result in infertility in men. Testicular atrophy may also be seen in young boys at puberty.[symptoma.com]
  • Decreased sperm count, decreased motility of sperm, and an increase in the number of deformed sperm are related to varicoceles.[radiology.ucsf.edu]
  • Other signs of varicoceles can be a decreased sperm count; decreased motility, or movement, of sperm; and an increase in the number of deformed sperm.[indianinterventionalradiology.com]
  • Varicocoeles may cause decreased sperm count, decreased motility of sperm, or an increase in the number of deformed sperm. Testicular atrophy Another symptom of varicocoeles is the shrinkage of the testicles, also known as atrophy.[bsir.org]

Treatment

Varicocele treatment may not be necessary until it causes pain, testicular atrophy or infertility in men. There are both surgical and non-surgical options available to treat a varicocele. The purpose of treatment is to seal off affected veins to redirect the blood flow into normal veins.

  • Varicocele embolization: A catheter directed varicocele embolization is a nonsurgical treatment that is highly effective to treat symptomatic varicoceles [5] [6]. A thin catheter is passed directly to the testicular vein at the groin under local anesthesia. The abnormal veins can be blocked by using coils or sclerosants under direct visualization of the veins. By embolizing the vein, blood flow is redirected to normal veins through alternate pathways.
  • Varicocelectomy: The most common surgical procedure to treat varicocele is surgical ligation which is known as varicocelectomy [7]. The most common approaches are inguinal, retroperitoneal and subinguinal [8]. A specially designed surgical instrument can be used to cut the veins by making two small incisions in the groin under general anesthesia. Patients of open surgical ligation can expect a two to three week recovery period.
  • Medical treatment with L-carnitine also has a beneficial effect [9] [10].

Prognosis

Varicoceles may be harmless but in some cases they can cause infertility and pain. About 2% to 5% of patients develop a condition called hydrocele. There are studies showing improvement in sperm quality in 57% of the cases after varicocelectomy. Recurrences are common and occur in 5% to 20% of the cases.

Etiology

Varicoceles usually develop in men older than 40 years of age due to blockage of large veins higher in abdomen. The major risk factors associated with varicocele include obesity and tumor masses such as kidney tumor. Both of these conditions cause pressure on the veins which can block blood flow to the veins.

The majority of varicoceles develop in teenagers and young men and are not due to a serious condition. There may also be a genetic cause of varicocele as the condition occurs usually in individuals of the same family.

Epidemiology

Varicoceles are a relatively common condition affecting approximately 10 percent of men. These are more common in young men, usually during the second and third decade of life.

About 40 percent cases of infertility in men occur due to varicoceles. Nine out of ten varicoceles develop in the left testicles, although it can be bilateral at the same time. The prevalence of varicocele may be as high as 80%.

Sex distribution
Age distribution

Pathophysiology

A varicocele forms when the valves inside the veins in the spermatic cord do not function properly. In healthy veins within the scrotum, one-way valves allow blood to flow from testicles and scrotum back to the heart. In varicoceles, the poor functioning valves and increased resistance to blood flow result in increased venous pressure. This can cause dilation and tortuosity of the pampiniform plexus, which is a network of veins that drain the testicle.

One of the main functions of the plexus is to lower the temperature of the testicles; varicoceles cause this function to be lost and lead to a higher temperature of the testes causing testicular atrophy. Due to reduction in the supply of oxygenated blood and nutrient material to the sperm production sites, the quality and the quantity of the sperms is affected, causing infertility in men [2].

A secondary varicocele is due to compression of the venous drainage of the testicle [3] [4]. The most common cause is renal cell carcinoma. One non-malignant cause of a secondary varicocele is Nut-cracker syndrome, a condition in which superior mesenteric artery compresses the left renal vein causing increased pressure to be transmitted into the left pampiniform plexus.

Prevention

A varicocele cannot be prevented from developing; however, the preventive measures that can be helpful include self-monitoring, regular checking of testicles every month knowing what they look and feel like, and look for any change in the shape and size of scrotum.

As high temperatures can trigger a wide veins around the testicles, so being in a room with high temperature continuously must be avoided. Moreover, it is recommended to wear special pants as protector and avoid too much wear jeans or tights. The activities such as unskilled labor, heavy weight lifting must be avoided to prevent varicoceles.

Summary

Varicocele is a mass of enlarged and dilated veins within the scrotum [1]. It is a varicose vein of the testicle and scrotum that may cause pain and lead to testicular shrinkage.

The condition is usually characterized by visible veins and feeling of heaviness in the testicle. Varicoceles are a common cause of infertility in men due to poor quality of the sperms that are produced in this disorder.

Varicoceles are observed in 15% of the male population and are generally acquired during puberty. If a varicocele causes symptoms, it can be repaired surgically.

Patient Information

Varicocele is the swelling of veins inside the scrotum. The condition is common in young boys at puberty and men older than 40 years of age. The patients usually present with visible enlarged veins, pain within the scrotum and feeling of heaviness in the testicle. It can be treated by surgical procedure.

References

Article

  1. Agger P. [Scrotal varicocele. A review]. Ugeskrift for laeger. Feb 14 1972;134(7):317-320.
  2. Lu YQ, Chen B. [Progress in researches on the mechanism of varicocele-induced male infertility]. Zhonghua nan ke xue = National journal of andrology. May 2008;14(5):454-458.
  3. Masuda F, Kudo K, Sasaki T, Onodera S, Machida T. [Varicocele as a symptom in renal cell carcinoma (author's transl)]. Nihon Hinyokika Gakkai zasshi. The japanese journal of urology. Dec 1975;66(12):876-880.
  4. Espinosa Bravo R, Lemourt Oliva M, Perez Monzon AF, et al. [Renal cell carcinoma and simultaneous left varicocele]. Archivos espanoles de urologia. Jun 2003;56(5):533-535.
  5. Gonzalez R, Narayan P, Castaneda-Zuniga WR, Amplatz K. Transvenous embolization of the internal spermatic veins for the treatment of varicocele scroti. The Urologic clinics of North America. Feb 1982;9(1):177-184.
  6. Gonzalez R, Narayan P, Formanek A, Amplatz K. Transvenous embolization of internal spermatic veins: nonoperative approach to treatment of varicocele. Urology. Mar 1981;17(3):246-248.
  7. Raheem OA. Surgical management of adolescent varicocele: Systematic review of the world literature. Urology annals. Jul 2013;5(3):133-139.
  8. Zini A. Varicocelectomy: microsurgical subinguinal technique is the treatment of choice. Canadian Urological Association journal = Journal de l'Association des urologues du Canada. Sep 2007;1(3):273-276.
  9. Cavallini G, Ferraretti AP, Gianaroli L, Biagiotti G, Vitali G. Cinnoxicam and L-carnitine/acetyl-L-carnitine treatment for idiopathic and varicocele-associated oligoasthenospermia. Journal of andrology. Sep-Oct 2004;25(5):761-770; discussion 771-762.
  10. Akdemir S, Gurocak S, Konac E, et al. Different surgical techniques and L-carnitine supplementation in an experimental varicocele model. Andrologia. Oct 10 2013.

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Last updated: 2019-07-11 22:33