Varicocele

Definition

A varicocele is an enlargement of the veins within the scrotum, the loose bag of skin that holds your testicles. A varicocele is similar to a varicose vein that can occur in your leg.

About one in six men have a varicocele. For males who are infertile, the figure is higher — about 40 percent. Varicoceles are the most common cause of low sperm production and decreased sperm quality, although not all varicoceles affect sperm production.

Most varicoceles develop over time. Fortunately, most varicoceles are easy to diagnose and, if they cause symptoms, can be repaired surgically.

Symptoms

A varicocele often produces no symptoms. Rarely, it may cause pain that may worsen over the course of a day because of physical exertion and typically is relieved by lying down on your back. With time, varicoceles may grow larger and become more noticeable.

Causes

The spermatic cord, which supplies blood to and returns blood from the testicle, houses the vas deferens, which carries sperm from the testicles. The pampiniform plexus is a group of veins within the scrotum and above the testicles. The pampiniform plexus drains blood from the testicles. Enlargement of these veins often occurs during puberty.

It's not certain what causes varicoceles, but many experts believe abnormal valves within the veins prevent normal blood flow. The resulting backup causes the veins to widen (dilate).

Varicoceles usually occur in the region of the left testicle, most likely because of the position of the left testicular vein. However, a varicocele in one testicle can affect sperm production in both testicles.

Tests

Your doctor will conduct a physical exam, which may reveal a twisted, nontender mass above your testicle. Some people have described the mass as feeling like a bag of worms. If it's large enough, your doctor will be able to feel it while you're standing up. If you have a smaller varicocele, your doctor may ask you to take a deep breath and hold it while you bear down (Valsalva maneuver). This helps your doctor detect abnormal enlargement of the veins.

If the physical exam is inconclusive, your doctor may order a scrotal ultrasound. This test, which uses high-frequency sound waves to create precise images of structures inside your body, may be used to ensure there isn't another reason for your symptoms. One such condition is a tumor that compresses the spermatic vein.

Treatments

Varicocele treatment may not be necessary. However, if you're infertile or your varicocele causes pain or testicular atrophy, you may want to undergo varicocele repair. Treatment is aimed at sealing off the affected vein to redirect the blood flow into normal veins.

Although varicoceles typically develop in adolescence, it's less clear whether you should have varicocele repair at that time. Indications for repairing a varicocele in adolescence include progressive testicular atrophy, pain or abnormal semen analysis results.

Varicocele repair presents relatively few risks. Increased fluid around the testicles (hydrocele) occurs in a small percentage of cases. Recurrence of varicoceles is a risk, affecting perhaps one in 10 men who undergo repair. Repair methods include:

  • Open surgery. This most common form of treatment usually is done on an outpatient basis, using general or local anesthetic. Your surgeon may approach the vein through your groin (transinguinal), abdomen (retroperitoneal) or below your groin (infrainguinal/infrapubic). Transinguinal surgery is most frequently used.
  • Recovery after surgical repair usually proceeds rapidly. Your doctor may advise you to return to normal activities that aren't strenuous after two days. As long as you're not uncomfortable, you may return to more strenuous normal activity, such as exercising, after two weeks. Pain resulting from this surgery is generally mild. Your doctor may prescribe pain medication for the first two days after surgery. After that, your doctor may advise you to take over-the-counter (OTC) painkillers, such as acetaminophen (Tylenol, others) or ibuprofen (Motrin, Advil, others) to relieve discomfort.
  • Your doctor may advise you not to have sexual intercourse for one week. It takes about 72 days for sperm to generate, so you'll have to wait three or four months after surgery to get a semen analysis to determine whether the varicocele repair was successful in restoring your fertility.
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