A varicocele is an abnormal dilation of the veins within the spermatic cord and is most commonly diagnosed by physical exam, venography (injection of dye in the vein followed by an x-ray), or color duplex ultrasound (where vein measurement and blood flow patterns are observed).

Incidence

15% of all men and 40% of infertility patients are found to have a varicocele. Approximately 90% are left-sided and 10% are bilateral.

Etiology (Cause)

There are many theories as to the reason varicoceles occur: 1) The left internal spermatic vein is 8-10 centimeters longer than the right and acts as a hydrostatic column with increased pressure in the upright position. 2) There are 40% fewer valves in the left spermatic veins as compared with 23% fewer on the right. 3) "Nutcracker Phenomenon" (compression of the left renal vein between major blood vessels) with increased pressure in the left internal spermatic vein.

Problems Caused by Varicoceles

• Elevated scrotal temperatures alter development maturation of sperm.
• Alteration of hormones (messengers) between the hypothalamus (upper brain), pituitary (main message center in the brain) and the testicles.
• Stagnation of blood around the testicles.
• Loss of testicular mass at the microscopic level.
• A varicocele on one side can deleteriously affect that testicle as well as the opposite testicle.
• Semen analyses may show decreased counts, decreased motility (swimming ability), increased number of abnormally shaped sperm, and abnormal sperm function (e.g. on a sperm penetration assay).

Treatment of Varicoceles

1) Surgical Varicocelectomy

• Benefits:  
  • 100% occlusion rate and 5% recurrence rate
  • 66% of men with improvement in seminal parameters
  • 43% of men achieves a pregnancy
• Risks of procedure:
  • 5% Wound infection
  • 3% Epididymitis (inflammation of the epididymis)
  • 3% Hydrocele formation (fluid around the testicle)
  • 1% Nerve injury leading to numbness in groin and scrotum
  • <1% Loss of testicle from damage to the testicular artery
• Post-Procedure process: 
  • A semen analysis is checked approximately 4 months after either procedure
  • Improvement in some aspect of the semen analysis may be noted soon after surgery and should continue to improve with time
• Recommendations after surgery:
  • No heavy lifting (greater than 10 pounds) for 5-7 days
  • No sexual activity for one week

2) Percutaneous Radiographic Embolization

• Benefits:
  • 70% occlusion rate and 5% recurrence rate
  • Diagnosis and treatment of subclinical varicoceles (those not seen or felt on exam)
  • Optimal treatment after surgical failure
  • Immediate recovery/no lifting restrictions
      
• Risks of procedure (11%):
  • Extravasation (catheter comes out of the vein)
  • Allergic reactions to dye -Inflammation of the veins in the testicles from sclerosing agents
  • Accidental puncture of femoral artery with femoral approach
  • Venous Spasm
  • Pain
     

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