Varicocele

Fertility treatments

Varicocele

Varicocele is found in 15% of the fertile male population, and 40% in infertile men, and has been described as hereditary in many studies where it has been suggested that siblings and children of men with varicocele are at increased risk.

Varicocele

Table of Contents

definition

What is Varicocele?

It is an anatomoclinical syndrome characterized by dilation and tortuosity of the testicular veins of the pampiniform plexus, caused mainly by venous reflux. It is a high prevalence pathology, with a chronic and progressive course.

Its onset usually occurs in adolescence, but most cases are diagnosed in adulthood. It usually occurs on the left side in 70%-75%, followed by the right side (15%-20%), or bilaterally in 10%.

Dilation of the testicular veins has been related to infertility, presenting a decrease of the spermatozoa, their mobility, morphology and capacity of fecundation, being these changes irreversible or not.

Varicocele is found in 15% of the fertile male population, and 40% in infertile men, and has been described as hereditary in many studies where it has been suggested that siblings and children of men with varicocele are at increased risk.

Testicle anatomy

treatment summary

Varicocele

This is short summary of the whole process: from the appointment request, to receiving the medical discharge after the treatment in some our Andromedi centers in Madrid, Seville or Canary islands (Tenerife)

Consultations Needed

Because it is a urological medical emergency and because it has a very particular symptomatology, the diagnosis can be made in a single consultation.

Hospital Stay

The hospital stay is usually very short, about 24 hours to wait for the anesthesia to wear off.

Anesthesia Type

Almost always and with the newest approaches, anesthesia is local with general sedation. The open technique requires general anesthesia.

Operation Time

Varicocele surgery is usually quite fast, in less than an hour the patient can be in and out of the operating room.

Post-operative

Light physical exercise is recommended to encourage recovery and return to sexual activity three weeks after the operation.

Resuming Sex Life

Daily activities can be resumed after 48 and 72 hours after surgery without any problem, without exaggerating.

Frequent causes

Causes

It is considered a multifactorial pathology, whose aetiology is not totally defined, however, the frequency of varicocele is much higher on the left side, in 90% of the total cases, for this reason, it has been correlated with alterations in the venous drainage of the left testicle, finding venous reflux and increased pressure in the drainage of the left spermatic vein to the renal vein on the left side.

Among the possible causes that would explain this dysfunction in patients with varicocele are:

Varicocele e infertilidad

Since 1880 a relationship between the presence of varicocele and infertility was discovered, this could be explained by the modifications at the level of tissue and testicular function that occur in this disease.

For normal sperm development, a temperature of approximately 33°C is required. At this temperature, the DNA suffers less oxidative damage, and therefore there is less chance of genetic mutation; this explains the scrotal location of the testicles. In addition to the strategic anatomical location, the pampiniform plexus helps to cool the blood coming from the testicular artery, thus contributing to the optimal temperature required by the testicles. For this reason, any alteration in the veins and consequently varicocele contributes to the increase of the scrotal temperature and deficiencies in the quality of the sperm.

The alterations in the microvasculature and in the testicular blood supply seen in varicocele, cause a state of sustained vasoconstriction which alters the supply of oxygen, nutrients and transport of hormones which affects the formation of sperm.

In addition, lower plasma testosterone concentration has been observed in patients with varicocele, which is why this pathology has been related to alterations in the cells that produce this hormone, the Ley dig cells.

Another alteration that occurs in patients with varicocele and is related to infertility, is testicular atrophy, observed in up to 70% of patients with varicocele, the testicle that is ipsilateral to venous dilations has been found decreased, with greater testicular atrophy in varicocele grades 2 and 3, but showing a significant improvement in adolescents who have the diagnosis and surgical treatment made in time.

In most cases, the varicocele grade is directly proportional to the effect on sperm quality, both in sperm count and in sperm quality

· Classification ·

1 Grade 3: Visible and palpable without Valsalva manoeuvres.

andromedi evolucion negativa de varicocele 03

Negative evolution of varicocele. 3rd grade

andromedi evolucion negativa de varicocele 03

Negative evolution of varicocele. Grade 2

2 Grade 2: Visible and palpable with Valsalva maneuvers.

andromedi evolucion negativa de varicocele 03

3 Grade 1: Palpable during Valsalva manoeuvres but not visible.

andromedi evolucion negativa de varicocele 01

Negative evolution of varicocele. Grade 1

4 Grade 0 (subclinical): Not palpable or visible at rest or during Valsalva manoeuvres, but reflux is shown on Doppler examination.

Depending on its location, it is classified as:

Unilateral
Unilateral

When venous dilation occurs in a single testicle.

Bilateral
Bilateral

When there is dilation and tortuosity in the veins of both testicles.

Unilateral
Unilateral

Cuando la dilatación venosa se presenta en un solo testículo.

Bilateral
Bilateral

Cuando se presenta dilatación y tortuosidad en las venas de los dos testículos.

symptomatology

Symptoms

It is generally an asymptomatic pathology, but it may present some symptoms such as testicular pain or weight or mass sensation in the scrotal region. A very significant sign is the decrease in testicular size, which may evolve into testicular atrophy.

There are other testicular pathologies that can cause these same symptoms and the doctor will have to make a differential diagnosis, such as orchiepididymitis, testicular torsion, allergic scrotum, testicular tumour, epididymis cyst or inguinal-scrotal hernia.

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En cumplimiento del Reglamento General de Protección de Datos le informamos que los datos por Vd. proporcionados serán objeto de tratamiento por parte de Andromedi con la finalidad de prestarle el servicio solicitado y/o contratado. Los datos no se cederán a terceros salvo en los casos en que exista una obligación legal. Para más información puede consultarla pinchando aquí.

Medical Evaluation

Diagnosis

For the study of the patient with suspected varicocele, a medical and reproductive history, complete physical examination, and seminograms should be taken into account.

Varicocele is diagnosed by physical examination, it is necessary to evaluate the patient in supine position and standing, an observation is made in search of obvious venous dilations in the scrotum, then a bilateral manual testicular examination is performed in supine position, standing and asking the patient to execute the Valsalva manoeuvres, which cause increased abdominal pressure and venous dilation.

For an optimal physical examination, the temperature of the environment should not be cold, since this produce elevation of the testicles, the ideal temperature being above 25 degrees Celsius.

Another important parameter to take into account is the testicular size. Approximate measurement is obtained by means of an orchidometer, the most commonly used being Prader’s, which consists of ovoid figures that vary between 2 cm3 and 25 cm3 and are compared with both testicles and with Tanner’s degree of pubertal development. In fully developed testicles, a difference of more than 2 cm3 between the two testicles is not normal.

Another element to be evaluated is testicular consistency, which is firm in a normal testicle but decreases notably in grade 2 and 3 varicoceles.

If clinical varicocele is not observed on examination, subclinical varicocele must be ruled out, and this is done by using conventional ultrasound, Doppler ultrasound, venography and tomography; Doppler and conventional ultrasound being the most used tests.

Doppler’s ultrasound allows the measurement of testicular volume, resistance index and direction if it is retrograde or anterograde, such measurement is performed with the patient standing, lying down or applying the Valsalva manoeuvre, this test not only helps to confirm the suspected diagnosis, but also corroborates the varicocele grade by allowing the measurement of the diameter of the vein pre and post-Valsalva.

A diagnosis of varicocele can be made when the pampiniform plexus veins are tortuous and a diameter greater than 2-3 mm is observed, increasing when standing, veins with a diameter of less than 2 mm being the norm.

Sperm phlebography: this is a somewhat invasive technique to be used on a regular basis, but it has proved to be of great help in cases of recurrence, as it helps to identify the anatomical position of recurrent or persistent sperm veins that are not occluded following varicocelectomy.

TECHNIQUES AND TREATMENTS

Semen analysis and varicocele.

It has already been proven that any grade of varicocele can considerably affect a man’s fertility. For this reason, whenever a diagnosis of varicocele is made, at least two semen analysis should be indicated, in order to evaluate the functional involvement of the varicocele in fertility and to make a surgical decision.

Among the alterations that can be observed in the semen analysis, we have an increase in the number of dead spermatozoa and abnormal forms with a decrease in their mobility and vitality. The most considerable changes that could occur are a marked decrease in the number and concentration of spermatozoa, which is considered a “stress pattern” in the semen analysis, without presenting alterations in the seminal fluid since the function of the prostate and seminal vesicles is not altered.

Early detection and adequate follow-up are recommended for adolescents with varicoceles,

since alterations have been observed on semen analysis since the early age of 13, such as a decrease in the motility and number of spermatozoa in these patients, versus those adolescents who do not have the disease. It should be taken into account that varicocele is a chronic and progressive pathology, which in adulthood can considerably compromise an individual’s fertility rate.

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Techniques and treatment

Treatment

There are several aspects that must be evaluated in order to consider surgical treatment in a patient with varicocele, among these we have:

The surgical treatment will be done with the objective of recovering the reproductive capacity of the patient, correcting testicular pain, preventing or reversing testicular atrophy in the case of adolescents or young patients and improving the individual’s production of androgens.

The most frequent surgical techniques are:

Inguinal Approach (Ivanissevich)

This technique allows the spermatic cord to be approached along the inguinal canal and in this way the spermatic vein(s) and the collateral cremasteric veins can be ligated. This technique is the most indicated in obese patients and has the advantage that it allows the external sperm vein to be ligated.

Subinguinal Approach

It is considered the one of choice because it has shown less postoperative pain, better recovery, allows arterial preservation and there is no need to open the aponeurosis of the external oblique; also, it serves as a choice when there is a history of previous inguinal surgery. The disadvantage is that the number of veins is greater and the risk of arterial injury ­increases.

Currently, varicocelectomy with subinguinal approach is widely used, but with the use of magnifying glasses, which help the surgeon to see everything four times larger and amplify all the structures, thus achieving a more thorough and effective surgery. With this technique, the testicular artery and lymphatic vessels are easily identified so as not to be damaged and to avoid complications such as hydrocele and hematomas. At the same time, it allows the surgeon to see all the veins clearly, to carefully separate and ligate them to correct varicose dilation. It has a recurrence rate of less than 3% and less than 1% of complications, which makes it an excellent surgical option.

The inguinal and subinguinal approaches have the advantage of allowing access to external sperm veins and even gubernaculum testis veins, which are often involved in recurrences. In addition, in case of need, this approach allows for a testicular biopsy or ­examination of the epididymis.

Retroperitoneal (Palomo) approach.
  • This is an approach used in thin patients who have previously undergone surgery by other means. It has the disadvantage of not including the external spermatic vein, which would lead to a higher probability of recurrence.
Laparoscopic technique
  • It has been considered a very effective, popular and easily performed technique by surgeons specialized in laparoscopic interventions. It has considerable advantages such as a better visualization of the spermatic vessels, as well as the detection of collateral venous branches, few complications and recurrences and a quick return to daily activities.

Although many studies confirm that success and complication rates are similar to open surgery, taking into account that it also requires general anaesthesia.

Microsurgical techniques

Being a highly specialized technique, it provides an excellent vision of the surgical field, by means of magnifying lenses and specific instruments it allows to preserve the spermatic artery, the cremasteric ­artery, the lymphatic vessels and the deferens with its vessels, and to perform with precision the ligation and section of the spermatic vein. It has the advantage of having a low rate of post-operative complications

Venous embolization

Is a minimally invasive technique, which does not require general anaesthesia and has a short period of hospitalization. With radiological assistance an introductory device is placed in the right common femoral vein through which the guide and catheter will be inserted, which will be guided to the left spermatic vein, where some metallic coils will be placed at different levels of the spermatic vein. 6-8 coils can be used, choosing them according to the diameter of the vein, the objective of this technique is the occlusion of the collateral veins and trying to decrease the recurrence rate.

"In our centres in Madrid, Seville or the Canary Islands (Tenerife), we carry out the techniques and treatments with the most modern facilities and the best specialists and equipment to guarantee an effective solution".

Complications

Although this surgery has a low risk and complication rate, some cases may occur such as:

Frequently asked questions at the Andromedi centres in Madrid, Seville and Tenerife

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Does varicocele predispose the patient to testicular cancer?

There are no studies that show that the presence of varicocele contributes as a direct cause in testicular cancer, however, the two conditions can coexist in an individual.

What results can I expect after a varicocelectomy?
When varicocelectomy is performed in a young patient, with an adequate surgical approach and an optimal medical-surgical team, very favourable results can be observed, such as:
  • Improved sperm quality in 50-70% of the cases operated on.
  • There is a great rate of pregnancies after the operation, ranging between 30 and 60%, usually the pregnancy is achieved after 8 months to a year of the varicocelectomy.
  • The deterioration of testicular function and tissue is stopped and there is also an improvement in testosterone levels.
  • The decrease in testicle size can be reversed if it is done at the time of diagnosis. In most adolescents and young adults, the testicle increases in size after varicocele surgery.
What are the recovery and post-operative care that must be taken?

It is a short surgery, lasts approximately less than an hour, the time of hospitalization is usually 24 hours, to assess the presence of immediate complications.

Daily activities can be resumed after 48-72 hours, as long as the person does not have a routine that involves great physical effort.

It is recommended to do light physical exercise and resume sexual activity after 3 weeks of surgery, after the surgeon has checked that the surgical wound is healing well and that no complications have developed.

Within the care, it is very important to clean the surgical wound with antiseptic solutions, changing the bandages daily. For the inflammation and discomfort that can occur in the testicles, it is recommended to use anti-inflammatory analgesics prescribed by the treating physician and to apply local cold.

Is there any relation between varicocele and infertility?

It has been shown that the presence of varicocele directly influences a man’s fertility. Figures show that 30 to 40% of men who present infertility have this pathology.  

Varicocele generates greater oxidative stress and alterations in the genetic load of the sperm, a product of venous reflux and the elevation of scrotal temperature that leads to testicular dysfunction.

Can a man with varicocele lead to a natural pregnancy?
This will depend on the grade of varicocele the man has, if he has a mild grade and short time of evolution which has not affected his sperm quality, he can achieve pregnancy of the couple without problems. It is important to take into account that the greater the grade and time of evolution of the disease, the more the fertility of the individual will be compromised.
Can varicocele reduce libido?
There is no direct cause for men suffering from varicocele to have decreased sexual desire, however, in severe forms of the disease, there is a decrease in testosterone levels, which could lead to decreased libido, in severe cases it could be a reason for sexual impotence.
Can you have sex if you have varicocele?
Yes, in case the pain or discomfort in the testicles does not represent a problem to carry out the sexual act.

 

Author

Dr. Natalio Cruz


Natalio Cruz MD, with 25 years of medical experience, has been until 2016 Head of the Andrology Unit in the Urology Service of the Virgen del Rocío Hospital in Seville, National Coordinator of Andrology in the Spanish Association of Urology (AEU) and General Secretary in the ESSM, positions that he has narrowed to focus squarely on this exciting project of offering a high-level private medical consultation in Seville, Madrid and Tenerife.

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Andromedi Clinic of Urology and Sexual Medicine

Thank you all for your comments and suggestions, we are happy to be of use in the medical and scientific dissemination around Urology and Sexual Medicine.

We try to answer as much as possible all the doubts that you raise here in the comments section. In a limited channel such as this, we cannot (and should not) respond in depth to personal or particular cases, but we can delve into general information.

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SHAW

Are you going through AZOOSPERMIA, LOW SPERM COUNT OR PREMATURE EJACULATION? Contact Dr. for a lifetime solution to your problem. I was once a victim of azoospermia which almost ruined my life & marriage for 18 years of childlessness, I used different kinds of medicine it was all to no avail. Until I read from someone who got treated/cured by the doctor, I reached out to him and I was able to impregnate my wife after 18 years of marriage, and am now a father. Your case will be corrected by Dr.

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