If you're familiar with "varicose veins" in the legs you can understand varicoceles as the same condition, dilated (enlarged) group of veins, but in the scrotum. The dilated veins are filled with excess blood.
First, a little background on how the blood flow works and its relation to varicoceles. 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. Men 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.
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Varicoceles most commonly develop during adolescence when the testes grow dramatically and therefore need more blood delivered to supply the increased need for oxygen and nutrients. Since more blood is going into the testes, 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.
If large varicoceles develop in a man after adolescence, he must be examined to make sure that there is no tumor in the abdomen pushing and compressing the veins, making the blood unable to properly flow back to the heart.
If you have this condition here are some of the ways it may be affecting you:
- Varicoceles may cause infertility through a significant decrease in the quality and quantity of the sperm.
- Varicoceles may cause damage to the testicles; they may not grow appropriately. This damage is progressive; it will often worsen over time. If an adolescent has a one-sided varicocele, the testis on that side may not develop as much as the other side and may be significantly smaller. This is a serious consideration because smaller testes generally produce significantly less sperm than normal-sized testes. If the varicocele is repaired during adolescence, the testis may experience catch-up growth and normalize in size. If it is repaired at a later age, the testis will not improve in size, though it may often improve in sperm production. The sperm production, however, will still not improve to the same extent it would have had it been repaired earlier.
- Varicoceles may cause discomfort leading to a heavy, dragging feeling in the scrotum.
- The testis, besides making sperm, also makes testosterone, the main male hormone. Testosterone is responsible for a man'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.
Fifteen percent of all men have varicoceles. (This was measured by examining military recruits, who represented a good cross section of men mostly before they had tried to father children.). However, forty percent of men who are experiencing "primary infertility" (have never fathered a biological child) have varicoceles.
Eighty percent of men with secondary fertility (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.
Of those men who have varicoceles, forty-five percent have varicoceles on both sides; fifty percent have a left-side varicocele; and five percent have a varicocele on the right side alone.
Although we know that varicoceles definitely decrease fertility we’re still not positive why this is so, but 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, men may notice their testicles move close into the body as the muscles in the scrotum wall (the cremasteric muscles) tighten. In warm weather, the cremasteric muscles relax and lengthen, allowing the testicles to hang away from a man'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 testes are near these veins, they will be kept at a higher temperature than is beneficial for them. Even if a man 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 men who have a large one-sided varicocele that has damaged the testis on one side, making it smaller. The small testis 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 testis 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 testes 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.
It used to be thought that a varicocele would result in a stress pattern that would appear in the semen analysis (i.e., a decreased percentage of moving sperm or sperm with abnormally shaped heads). Recent studies conclude that varicoceles affect virtually all of the parameters in a semen analysis (i.e., the concentration, motility, forward progression, and morphology). The varicoceles also affect the functioning of the sperm, although this cannot be tested by a routine semen analysis. Very specialized testing of the sperm functioning may be performed, although this is expensive and its use is debated.
How is varicoceles diagnosed? Let's go into a few of the ways:
Many men 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 men 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 a man is standing and again, it will feel like a bag of spaghetti. It may disappear when a man 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 man 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 testis is performed. The diameter of the veins can be measured. Other abnormalities may be identified. A recent study found that thirty one percent of men with infertility had an abnormal finding on the ultrasound that was not suspected during the physical examination. 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.
VARICOCELE TREATMENT - VARICOCELECTOMY
What we call the gold standard for fixing a varicocele is the microscopic sub-inguinal varicocelectomy. Sub-inguinal 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. What's important about making the incision here is that the abdominal muscle can be avoided and that means much 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 clearly see all the veins that need to be severed, as well as the arteries and the lymphatics, which drain fluid from the space between the testes and the surrounding sac, to be avoided and not severed.
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 about one 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 are lots of pluses associated with this method: there is little discomfort associated with it and the recovery time is fairly quick. During the procedure, the patient feels almost nothing; in many 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 men go back to work after two to three days. Studies have shown that after this type of varicocelectomy, men use less pain medication than most people use after a typical dental procedure.
An alternate method of varicocele surgery is called an inguinal varicocelectomy. Although most infertility specialists use the microscopic sub-inguinal 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 sub-inguinal 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. 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. This means that the arteries bringing blood to the testicle are also usually not spared and there is a higher incidence of 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 to sever the veins further up (the retro-peritoneal 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%.
You can also choose to have a varicocele repaired laparoscopically, but here, 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.
Success rates of varicocele treatments can be measured in terms of resulting pregnancy rates: 60% 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 man 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.
A few more numbers from a study: This one looked at 25 men older than 45 years of age and showed an average preoperative concentration of 12.7 million/cc, a motility of 29.6%, and a normal morphology (shape of 24.4%). Postoperatively, the average concentration was 20.3 million/cc. The average motility was 44.7% and the average morphology was 30.7% normal morphology. It would appear that even older men with long standing varicoceles will show significant improvement from a varicocelectomy.
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.
You need to know is that it takes a minimum of four months to see any significant improvement in the semen analysis after a varicocelectomy. Increased improvements can often be seen for up to two years. If, however, there has been no improvement within six months, other options should be simultaneously considered.
A varicocelectomy does not in any way negatively affect the sperm, and, while waiting for improvement, additional and alternative steps can be taken by the couple.
FINDING A DOCTOR
Our recommendation is that you locate a urologist who has completed specialized training in male infertility (fellowships), and that you use this physician to perform your surgery.
After their general urological training, (five to six years post medical school) some physicians choose to complete additional training in infertility (a fellowship). During their fellowship, they are exposed to large numbers of men with infertility problems and focus on the diagnosis and treatment of these men.
A significant part of the advanced training is spent mastering microsurgery, surgery that is performed under an operating microscope. Facility with this technique enables them to perform the most sophisticated and least invasive surgeries appropriate to varicoceles as well as other male infertility surgeries (e.g., vas reconstruction).
Additionally, as part of their fellowship, these urologists are also trained to understand female infertility and the interface between the two disciplines. By now you understand that infertility is a couple's issue; physicians treating the couple should understand the medical issues of both parties and work comfortably with the couple and other involved physicians, using a team approach.