What is a varicocele?
A varicocele is a dilated (enlarged) group of veins in the scrotum. Just like some people have dilated or "varicose" veins in their legs, some adolescents have dilated veins in their scrotum. The dilated veins are filled with excess blood.
Every part of the body needs oxygen. Blood carries oxygen to various parts of the body through arteries. Arteries have muscular walls that pump the blood away from the heart. Veins are the channels that bring the blood back to the heart, and they do not have thick, muscular walls. Their walls are fairly thin, and the blood in them moves more passively. It is pushed back toward the heart through the pressure of the blood being pumped away from the heart and the movement of the muscles and other structures surrounding the veins pushing against the vein walls.
Interspersed along the veins are a series of one-way valves. These valves allow the blood to flow toward the heart but stop the blood from "slipping" backwards. If these valves are not working properly, blood will flow backwards and, because of gravity, the blood will collect in the most dependent (lowest) part of the pathway. In people who have large varicose veins in their legs, the valves are not functioning properly and the blood is actually pooling in their legs. Because of this, they will find that after standing for long periods of time, the blood has collected in their legs, giving them a heavy, dragging feeling. Adolescents with varicoceles may notice a heavy, dragging, aching feeling in the scrotum ("ball sack") at the end of the day. There, too, the valves in the veins that drain the blood from the testicles (the internal-spermatic veins) are not functioning properly and allow the blood to collect.
Causes and Prevalence
Varicoceles most commonly develop during adolescence when the testicles grow dramatically and therefore need more blood delivered to supply the increased need for oxygen and nutrients. Since more blood is going into the testicles, there is also more blood draining away from them. If the valves are not functioning properly, the extra blood cannot be handled by the veins, and the blood pools in the scrotum. It is estimated that 6% of boys aged 10 have varicoceles. This increases to 13.7% to 16.2% by age 15.
Fifteen percent of all adolescents have varicoceles. (This was measured by examining military recruits, who represented a good cross section of adolescents mostly before they had tried to father children.)
Of those adolescents who have varicoceles, 45% have varicoceles on both sides; 50% have a left-side varicocele; and 5% have a varicocele on the right side alone.
We are certain that varicoceles damage the testicle but we have not yet categorically determined why this is so. There are several theories:
- Increased temperature of the testicles: The testicles are located in the scrotum, which effectively regulates their temperature. They are maintained at a temperature slightly below body temperature. (This is probably why they are located outside the body rather than inside the body where they clearly would be better protected.) In cold weather, adolescents may notice their testicles move close into the body as the cremasteric muscles, the muscles in the scrotum wall, tighten. In warm weather, the cremasteric muscles relax and lengthen, allowing the testicles to hang away from an adolescent's body and cool down.
Some babies are born without their testicles having descended into their scrotum. They are trapped somewhere in their bodies and constantly exposed to body temperature. This is so harmful for the testicles that if they remain there past puberty, they will stop producing sperm altogether and have a higher chance of developing cancer. Therefore, if a boy's testicles do not descend into the scrotum by the time he is 12 months old, they should be surgically brought down and placed into the scrotum.
Varicoceles are a group of dilated veins filled with blood, which surround the testicles. The blood is at body temperature, and if the testicles are near these veins, they will be kept at a higher temperature than is beneficial for them. Even if an adolescent has a varicocele only on one side, the whole scrotum is warmed by the blood and both testicles can be negatively affected.
In general, larger testicles make more sperm than smaller testicles. Often, however, you see adolescents who have a large one-sided varicocele that has damaged the testicle on one side, making it smaller. The small testicle makes significantly less sperm than the normal one. However, even in the "normal" one, the sperm quality is often very low. The varicocele is not only damaging the testicle on the side where it is found, but also suppressing the sperm production on the opposite (better) side.
When a varicocele is repaired, the blood is no longer able to flow back into the scrotum. This affects not only the testicle on that side, but also the opposite side. With this normalization of temperature, there may be some dramatic improvement in sperm production. It is likely that this improvement comes mostly from improved production in the larger, better testicle.
- Increased waste products back-flowing into the testicle. The veins draining the testicles connect into larger veins. On the left side, they drain into the kidney vein, which is draining blood from the kidney. The blood from the kidney carries waste products, which may then drain backwards into the scrotum and collect there. This may negatively affect sperm production.
Varicoceles may cause subfertility (which will be described below) as well as have these negative effects.
- Varicoceles may cause discomfort leading to a heavy, dragging feeling in the scrotum.
- Varicoceles may be quite large, and embarrassing or worrisome to an adolescent male, most of whom are very concerned with being and looking normal.
- The testicles, besides making sperm, also make testosterone, the main male hormone. Testosterone is responsible for an adolescent's "secondary male characteristics" (i.e., increased muscle mass and tone, level of sexual interest, body hair). Varicoceles can damage the cells that make testosterone and may lead to a decreased overall testosterone level, which may either affect the adolescent in the present or, more likely, in the future.
Varicoceles and Infertility
Varicoceles may cause damage to the testicles, causing them to grow improperly. This damage is progressive; it will often worsen over time. If an adolescent has a one-sided varicocele, the testicle on that side may not develop as much as the other side and may be significantly smaller. This is a serious consideration because smaller testicles generally produce significantly less sperm than normal-sized testicles. If the varicocele is repaired during adolescence, the testicles usually experience catch-up growth and normalize in size. If it is repaired at a later age, the testicles will not improve in size, though it may often improve overall sperm production. The sperm production, however, will still not improve to the same extent as if it had been repaired earlier.
Thus, varicoceles are a common cause of future male factor infertility. Forty percent of men who are experiencing "primary infertility" (have never fathered a biological child) have varicoceles. Eighty percent of men with secondary infertility (they have fathered at least one biological child, but are not currently able to do so) have varicoceles. This may be due to the fact that varicoceles cause progressive damage to the testicle and a progressive decrease in the quality and quantity of sperm produced.
Varicoceles in adolescents may be diagnosed in a variety of manners.
Many adolescents know they have a varicocele because they can feel the mass of dilated veins in the scrotum. This feels like a sac of worms or spaghetti. These adolescents have larger varicoceles. They may also notice:
- The testicle is smaller on that side.
- They have discomfort in that testicle or side of the scrotum.
During a physical examination a physician may diagnose a varicocele. It can most clearly be felt when an adolescent is standing and again, it will feel like a bag of spaghetti. It may disappear when an adolescent lies down (as the weight of the blood and the veins is no longer pushing down past the malfunctioning valves into the scrotum). In a standing position, the adolescent may also be asked to bear down (like he is having a bowel movement). The physician may feel an impulse when the blood pushes backwards (because of the increased pressure inside the abdomen) into the scrotum.
To confirm varicoceles, sophisticated tests are often used.
- A Doppler stethoscope will amplify the sound of blood moving past it. When the patient pushes down, more blood flows backwards into the scrotum and can be heard as a rushing sound.
- Ultrasound: The duplex ultrasound is currently considered the best non-invasive way to identify or confirm the presence of varicoceles. The duplex ultrasound has two parts.
- First a thorough ultrasound of the testicles is performed. Other abnormalities may be identified. A recent study found that 31% of men with infertility had an abnormal finding on the ultrasound that was not suspected during the physical examination. The diameter of the veins draining the testicles can be measured.
- The second part of the ultrasound evaluation measures the blood that flows past the probe when the patient pushes down. This blood flow confirms the varicocele.
- Another test, rarely used anymore, involves injecting a radioactive substance into the blood stream. This can then be seen collecting in the scrotum.
Microscopic Subinguinal Varicocelectomy
The gold standard for fixing a varicocele (varicocelectomy) is the microscopic sub-inguinal approach. Subinguinal refers to the location of the incision. This single incision is about one inch above the top of the penis and one inch to either side. If both sides are being operated on, two incisions are made. The scars will later be covered by pubic hair. This is where the spermatic cord (the bundle carrying the vas deferens, the testicular arteries, the veins, the lymphatics, and the muscles) leaves the abdominal wall. By making the incision here, the abdominal muscle can be avoided, which results in significantly less postoperative discomfort and significantly reduced healing time.
Microscopic means that an operating microscope is used. This large microscope stands above the patient, and the doctor performs the delicate part of the operation while looking through it. This allows the surgeon to see clearly all the veins that need to be severed, while avoiding the arteries and the lymphatics, which drain fluid from the space between the testicle and the surrounding sac.
In this approach, a patient is usually sedated (asleep, but not intubated - this is safer for the patient). While sleeping, a local anesthetic is injected into the area. An incision of three quarters of an inch to one and a half inches is made in the numbed area. The spermatic bundle (cord) is located, grasped, and brought out of the patient's body. Using the microscope, the layers of muscle surrounding it are stripped away. The artery is identified and a tie loosely placed around it for identification. The veins are then sequentially located and severed. The cord is then placed back into the patient's body and the tissues are closed, layer by layer. The skin is generally closed with a plastic surgery stitch; the stitches are placed under the skin so that they need not be removed later.
There is little discomfort associated with this method and the recovery time is fairly quick. During the procedure, the patient feels almost nothing; in most cases, the patient completely sleeps through the procedure. The anesthesiologist can administer sedatives and an appropriate dosage of pain medication. There may be some discomfort, swelling, and bruises for several days afterward. Almost all adolescents go back to school or work after 2 to 3 days. Studies have shown that after this type of varicocelectomy, less pain medication is used than after a typical dental procedure.
The complication rate is the lowest for this method of surgery. Success rates (in terms of improved testicular function) are highest from this technique. It is the only one where the artery can be reliably preserved. (Intuitively, it makes sense that if you are trying to improve the function of an organ, you preserve its arterial supply!)
An alternate method of varicoceles surgery is called an inguinal varicocelectomy. Although most infertility specialists use the microscopic subinguinal approach, a varicocelectomy is sometimes performed by a general urologist. In this case, the incision is made just like a hernia incision. The abdominal muscles that cover the varicocele are cut at the point where they leave the abdomen. The cord is exposed. Then, using the naked eye or magnifying lenses worn as glasses, the veins are cut. The incision is longer than a subinguinal incision. It also is higher, making the scar visible above the pubic hair. Because the abdominal muscles are cut, the postoperative pain is significantly increased and the healing process takes longer. Also, if the microscope is not used, it is harder to see and spare the arteries and lymphatics or to see and sever all of the necessary veins. Thus, the arteries bringing blood to the testicle are also usually not spared and there is a higher incidence of short term failure (5% to 15%) and the formation of hydrocele, a collection of fluid around the testicle (3% to 30%).
The third method that may be used involves an even higher incision on the abdomen to sever the veins further up (the retroperitoneal approach). This leaves a more obvious and unusual scar. It also involves cutting abdominal muscles, which increases postoperative pain and recovery. The artery is not preserved. It has a failure rate of 15% to 25% and a risk of hydrocele formation of approximately 7%.
Finally, a varicocele may be repaired laparoscopically, but the patient must be placed under a general anesthetic. A catheter (tube) is placed into the bladder in order to allow the urine to drain out so that the bladder does not get in the way of the procedure. A small incision is made under the umbilicus (bellybutton) and the abdomen is filled with air. The needle is replaced with a larger, bored trocar (sharp tool) and a sheath so that the camera can be placed in the abdomen. Under vision, an additional two incisions are made in the abdominal wall and two working instruments are placed into the abdomen. The bundle carrying the vein and arteries is identified. At this point, this bundle is transected. Care is taken not to transect the vas accidentally.
This procedure is not generally recommended because it requires that the patient be under a general anesthesia, that a Foley catheter be inserted, and that instead of an incision outside the abdominal wall three incisions in the abdominal wall must be made. There are also inherent risks with laparoscopy that are greater than those with the small open procedure done with microscopic varicocelectomy.
When should an adolescent have a varicocele fixed?
In men, varicocelectomies are usually preformed in patients who have suboptimal semen analysis and demonstrated subfertility. However, this is rarely, if ever, the reason adolescent varicocelectomy is considered. In adolescents, varicocelectomy should be performed or at least strongly considered for:
- Pain: Many adolescents will complain of pain in the side of the scrotum (usually the left) where the varicocele is. Most will have significant resolution of their pain post-operatively.
- Decreased Size of the Testicles: Most boys with a large varicocele will have damage from the varicocele on the affected side. This is evidenced by a significant decrease in size. In a recent study, 89% of boys who had varicoceles repaired had a normalization in the size of the testicle (i.e., it caught up in growth, and was the same size as the other one). This has long term implications for fertility and testosterone production.
- Emotional Discomfort: Often the varicocele is either diagnosed by the boy himself or the pediatrician. The adolescent frequently finds the bulging and possible differentiation in size of the testicles upsetting (from an asthetic point of view) and worrisome. Thus, many adolescents are anxious to undergo varicocelectomy.
- Fertility: Most adolescents have not tried to achieve a pregnancy, though some may have done so (usually unintentionally). Varicocles are a progressive lesion, meaning that they have a progressively negative effect on the testicles and ultimately on sperm production. Certainly, if the affected testicle is smaller in size, this is a good indication that fertility may ultimately be compromised, and the varicocele should be repaired. In boys with a varicocele and no change in size of the testicle, a semen analysis can be done. If there are abnormalities in the analysis this would be a strong indication for a varicocelectomy.
Adolescent Semen Analysis:
There remains controversy over whether it is appropriate to do a semen analysis in an adolescent. However, depending on the age, most boys in their teens are masturbating regularly and many are sexually active. Each case is different, and many adolescents are quite comfortable with producing a specimen and anxious to do whatever they need to do, in order to be treated. The semen analysis is a valuable tool in many cases in deciding whether or not varicocelectomy should be performed. The option of performing a semen analysis should certainly be offered to the adolescent, privately, but with the consent of the parents (if he is a minor).
Testicular "Catch-up" Growth: As mentioned above, almost 90% of adolescents who have a smaller testicle on the affected side will have catch-up growth to that testicle post-operatively when microscopic subinguinal varicocelectomy is performed. This is, of course, important psychologically, as well as having implications for future fertility and testosterone production.
Fertility: Success rates of varicoceles treatment in men can be measured in terms of resulting pregnancy rates: Sixty percent of men will establish a pregnancy within one year of varicocelectomy. Seventy-two percent of men will do so after two years. This compares to 16% of men whose partners will conceive without undergoing a varicocelectomy during the same period.
Success rates can also be measured by change in semen analysis results. Sixty-five percent of men will show a significant improvement in the semen analysis within 12 months. A significant change is defined as a doubling of the total motile count. The total motile count is the calculated number of sperm that the adolescent actually ejaculates.
Men with larger varicoceles will show more significant improvement. In these men, 69% will have a three-fold improvement in the total motile count in the ejaculate. Many men have a large varicocele on one side and a small varicocele on the other side. A recent study addressed whether, in these cases, both varicoceles should be repaired or if just the larger one should. Sixty-five percent of men with bilateral (two-sided) varicoceles, with a small varicocele on one side and a large varicocele on the other, chose to have both varicoceles repaired.
This group showed a 104% increase in the total motile count. Twenty-six percent of the men decided to have surgery only on the left side and they showed an average improvement of 45% in the total motile count. In general, even if only a small varicocele is found on the opposite side of a large varicocele, it is recommended that they both be repaired.
It takes 78 days from the beginning of the sperms' development until they are ready to be ejaculated. This is a continuous process very much like an assembly line. At any given time, there should be millions of sperm at all stages of development.
It therefore takes a minimum of 4 months to see any significant improvement in the semen analysis after a varicocelectomy. Increased improvement can often be seen for up to two years.
Finding a Doctor
After their general urological training (5 to 6 years post medical school), some physicians choose to complete additional training in reproductive medicine and microsurgery (a fellowship). During their fellowship, they are exposed to large numbers of males with infertility problems and focus on the diagnosis and treatment of these males. These physicians usually have, by far, the most experience in the surgical treatment of varicoceles, as it is the most common cause of male factor fertility. The surgical treatment of varicoceles is the same in an adolescent or older male.
A significant part of the advanced training is spent mastering microsurgery, surgery that is performed under an operating microscope. Facility with this technique enables physicians to perform the most sophisticated and least invasive surgeries appropriate to varicoceles as well as other male infertility surgeries (e.g., vas reconstruction).
Pediatric urologists will also treat boys with varicoceles, and may have significant experience in doing so. However, it is important to establish which technique they plan to use, and how many they have done. Pediatric urologists are often trained or encouraged to do laparoscopic varicocelectomies, the disadvantages of which are outlined above.
Please note: In cases of undescended testicles, pediatric urologists have the most experience by far, and they should be the ones to perform the surgery to bring down a testicle no matter at what age this condition is discovered.
Adolescent varicocele is a significant medical issue.
- Decreased Testosterone Production
Proper evaluation is needed. Surgical repair is often indicated. Both the evaluation and, if necessary, the surgery should be performed by a urologist specializing in reproductive medicine and microsurgery.