Varicocele – Symptoms, Diagnosis and Treatment

Varicocele, and not “varicocele”, as some patients of an andrologist sometimes call this pathology, is a varicose vein of the testicles (testicles) / testicle and spermatic cord (a formation consisting of arteries, vas deferens, venous and nerve plexuses, lymphatic vessels ). The medical term is derived from the words “expansion” (Latin “varix”) and “tumor” (Greek “kele”).

This problem turns out to be very common: it is detected in approximately 15% (WHO – 11,7%) of the male population and has been known since the beginning of the millennium. Varicocele in men suffering from infertility is present in almost 40% (25,4% according to WHO data) of cases, and when it comes to secondary infertility, the disease is already recorded in 80% of episodes.

The frequency of left-sided lesions varies from 80% to 98%, right-sided – from 2,1% to 8,3%, bilateral – from 2,48% to 78,5%. In children, the disease is rare (0,12%), usually begins to develop during puberty and often goes unnoticed. Varicocele in men over 50 reaches (according to some data) 77,3%! This pathology in itself is not dangerous, but is a significant factor in the development of male infertility.

Varicocele causes

The disease is primary (according to medical terminology – idiopathic) and secondary (symptomatic), due to the presence of another pathology (enlarged lymph nodes, tumor, cysts).

The causes of varicocele remain the subject of active scientific discussion to this day. It is generally accepted that the expansion of the veins is due to increased pressure in them. In this regard, the causes of primary pathology can be: • Violation of the venous valves, which normally should prevent reverse blood flow. This condition leads to the fact that during exercise, the vertical position increases pressure in the veins. • Special vascular arrangement, renal vein with superior mesenteric artery, in which the left renal vein can be occluded. In a standing position, due to the action of natural gravity, such compression increases even more (it is for this reason that the pathology is formed mainly on the left side). • During puberty, a sharp increase in the flow of arterial blood to the testicles.

Varicocele symptoms

Very often, varicocele does not have any clinical manifestations at all and turns out to be an accidental finding during a physical examination. In some situations, there is a mild soreness of the testicle: pulling / bursting sensations that appear with tension or simply when the patient is standing.

Also, sometimes they may be disturbed by: • sagging of the scrotum, in the heat or in the process of walking, becoming more pronounced; • feeling of heaviness in the scrotum/groin; • directly in the testicle, in the area of ​​the spermatic cord – tingling, burning; • irradiation of pain in the thigh, penis, lower back, lower abdomen, perineum with intensification by the end of the day, when walking and weakening in the supine position, when lifting the scrotum; • decrease in erectile function; • poor general health, nervousness; • increased urination, enuresis (nighttime urinary incontinence), etc.

The severity of symptoms depends on the stage of development of the disease: in the later stages, the pain becomes constant, present and at rest. Atrophy / hypotrophy (decrease) or edema (in this case, an increase in size is observed) may develop, with an advanced form of testicular varicocele.

Diagnostic methods

Diagnostic measures for varicocele include palpation of the scrotum in a standing / lying position, assessment of the consistency, dimensional parameters of the testicles (through measurements, visually or using Prader’s ovals, etc.).

Additionally, the following can be carried out: • Doppler ultrasound to visualize the expansion of vascular, reverse blood reflux (the so-called reflux) in the patient’s standing position or during the implementation of the Valsalva test (with straining, holding the breath); • scrotal thermography/thermometry (temperature difference between the testicles is determined); • phlebography (filling of the veins with a radiopaque substance followed by x-ray examination).

When conducting a diagnostic examination for varicocele, it is possible to identify the presence of other concomitant pathologies: • prostatitis – an inflammatory lesion of the prostate (prostate gland); • vesiculitis – inflammation of the seminal vesicles; • inflammation of the testicles (orchitis) or their appendages (epididymitis); • urethritis – diseases of the inflammatory nature of the urethra; • tumor formations, cysts, inguinal hernia, etc.

Careful differential diagnosis is important, since varicocele can be disguised as: • dropsy (excessive formation and accumulation of fluid in the testicular membranes); • tumors of various types; • chronic epididymitis; • inflammatory lesion of the spermatic cord (funiculitis).

Laboratory methods can also be used: • general urinalysis, because due to increased pressure in the venous vessel, protein (proteinuria), erythrocytes (microhematuria) may appear in the urine, as a result of certain diseases – pyelonephritis (inflammatory process in the kidneys), urolithiasis and etc.; • semen analysis.

Classification of the disease

According to WHO recommendations, the following types of varicocele are distinguished: • subclinical – when the signs of the disease are detected exclusively on Doppler ultrasound or by means of thermography, and there are no symptoms; • I degree – changes in the veins are noted during the implementation of the Valsalva test; • II – veins are palpable, but not visible; • III – the vessels are not only palpated, but their protrusion is noticeable during visual inspection.

Based on the area in which the blood flow is disturbed or vasodilation occurs, the following types are distinguished: • renospermatic (the most common, up to 85% of all episodes) – pathology of the internal testicular, renal veins; • ileospermatic – external testicular, iliac veins; • the most rare – mixed.

Treatment of varicocele

Surgery is the only effective treatment for varicocele. However, since the disease is not dangerous, the need for surgery is determined by a number of factors: • orchalgia (pain in the testicles); • testicular hypotrophy from the side of the lesion; • male infertility; • pronounced aesthetic discomfort.

At the same time, when a pathology is detected in children or adolescents, a number of specialists strongly recommend that a procedure be performed to prevent the possible development of infertility. With a proven reduction in the testicle on the side of the lesion in adolescents, treatment is always required.

In men of reproductive age who plan to have children, with: • first degree (in which there are no changes in the spermogram in most episodes) – surgery is not indicated; • the second without changes in the spermogram – control (semen analysis every two years) and observation is recommended; • the second with changes in the spermogram – intervention is indicated; • third – almost always an operation is required.

To date, there are many types of surgical interventions (over 120 techniques!) For the treatment of varicocele. Interventions can occur as operations: • open type; • microsurgical (from mini-access, small incision); • laparoscopic – an endoscopic procedure, in which a mini-camera, clamp, scissors are inserted through three punctures (“pluses” – quick recovery, “minuses” – there is a risk of specific complications).

Depending on the area from which access to the site of the lesion is made, there are types of surgery: • subinguinal (Marmara, Goldstein) – with access (incision) below the outer inguinal ring, using optical devices, can be performed on an outpatient basis, the recurrence of varicocele after surgery is minimal, as and the risk of developing hydrocele (both problems occur in about 2% of cases with Marmar’s surgery); • inguinal (Ivanissevich) – with access at the level of the inguinal canal, with general anesthesia, optical devices can also be used, but recurrence and complications are more common (but in children and adolescents, the method is often preferred due to the thin artery, difficult to see from the subgroin access, and low pressure); • supragingal (Palomo) – anesthesia is required, the longest postoperative period, the risk of recurrence is somewhat lower than during Ivanissevich’s operation (but on average it can reach 25%).

There are other treatment options: • microsurgical testicular revascularization – transplantation into the epigastric testicular vein to restore normal blood flow; • endovascular techniques – embolization (blocking the vessel with a special stopper) or sclerotherapy (administration of sclerosing drugs that stop blood flow), etc.

In the general case, the choice of the method of surgical intervention is carried out by the doctor, based on a number of factors (the age of the patient, the presence of concomitant pathologies, the accumulated experience in the field of a particular technique with this doctor, etc.).

The prognosis of the success of surgical therapy due to infertility due to varicocele is affected by the following points: • age – the older the patient, the higher the duration of the disease and the degree of tissue damage, the lower the efficiency; • testicular volume – lower efficiency with a significant decrease in volume due to a long-term presence of varicocele; • bilateral nature of the lesion (with this option, patients may experience a complete absence of spermatozoa in the semen, azoospermia); • degree of pathology development; • quantitative level of follicle-stimulating hormone – in men, this hormone characterizes the degree of irreversible damage to the testicle, respectively, with high values, the prognosis of treatment carried out in order to restore spermatogenesis is disappointing.

Complications of the disease

By itself, varicocele is not a life-threatening pathology, but it can become a significant cause of such a problem as infertility. There are many theories explaining the development of such a complication: • an increase in testicular temperature (due to the gradual stretching of the veins, the formation of a kind of “cushion” and a violation of the thermoregulatory ability of the scrotum) from 34 degrees normal for this organ to body temperature, leading to the suppression of normal sperm production ( spermatogenesis); • mechanical compression of the affected veins of the ducts; • hypoxia (otherwise – ischemia), low oxygen saturation of testicular tissues due to blood stasis; • violation of the supply of nutrients to testicular tissues; • reflux from the kidneys and / or adrenal glands into the vein system of active substances, hormones that have a toxic effect on the tissue of the testicles; • the development of an autoimmune process, in which the protection of the testicles is disrupted and the body attacks its own spermatozoa; • Decreased production of testosterone (male sex hormone).

Prevention

There is no specific prevention of the development of varicocele, since the disease is caused by the presence of an anatomical / genetic predisposition. It is very important for young people to be examined by an andrologist or urologist in time and, if abnormalities are detected, be regularly observed or even undergo treatment.

In the presence of varicocele of the initial stage, doctors advise: • to avoid excessive exercise; • to exclude problems with a chair; • to refuse from bad habits; • have a regular sexual life; • to ensure sufficient good rest; • go in for sports (without overloads).

Given the possibility of developing a secondary varicocele, it is recommended to conduct regular self-examination and visit a specialist from time to time. In the event of the development of this type of problem, it is necessary to identify and eliminate its root cause in a timely manner.