Varicocele
Encyclopedia
Varicocele (ˈværɨkɵsiːl), also known as varicoscele or varicose seal, is an abnormal enlargement of the vein
that is in the scrotum
draining the testicles. The testicular blood vessels originate in the abdomen and course down through the inguinal canal
as part of the spermatic cord
on their way to the testis. Upward flow of blood in the veins is ensured by small one-way valves that prevent backflow. Defective valves, or compression of the vein by a nearby structure, can cause dilatation of the veins near the testis, leading to the formation of a varicocele.
varicocele occurs when the valves within the veins along the spermatic cord do not work properly. This is essentially the same process as varicose veins
, which are common in the legs. This results in backflow of blood into the pampiniform plexus
and causes increased pressures, ultimately leading to permanent damage to the testicular tissue.
Varicoceles develop slowly and may not have any symptoms. They are most frequently diagnosed when a patient is 15–30 years of age, and rarely develop after the age of 40. They occur in 15-20% of all males, and in 40% of infertile males.
98% of idiopathic varicoceles occur on the left side, apparently because the left testicular vein
connects to the renal vein
(and does so at a 90-degree angle), while the right testicular vein drains at less than 90-degrees directly into the significantly larger inferior vena cava
. Isolated right sided varicoceles are rare, and should prompt evaluation for an abdominal/ pelvic mass or a kidney cancer.
A secondary varicocele is due to compression of the venous drainage of the testicle. A pelvic or abdominal malignancy is a definite concern when a right-sided varicocele is newly diagnosed in a patient older than 40 years of age. One non-malignant cause of a secondary varicocele is the so-called "Nutcracker syndrome
", a condition in which the superior mesenteric artery
compresses the left renal vein, causing increased pressures there to be transmitted retrograde into the left pampiniform plexus. The most common cause is renal cell carcinoma
(a.k.a. hypernephroma) followed by retroperitoneal fibrosis or adhesions.
, which is the network of veins that drain the testicle. This plexus travels along the posterior portion of the testicle with the epididymis and vas deferens, and then into the spermatic cord. This network of veins coalesces into the gonadal, or testicular, vein
. The right gonadal vein drains into the inferior vena cava
, while the left gonadal vein drains into the left renal vein
at right angle to the renal vein, which then drains into the inferior vena cava.
The small vessels of the pampiniform plexus normally range from 0.5–1.5 mm in diameter. Dilatation of these vessels greater than 2 mm is called a varicocele.
When lying down, gravity may allow the drainage of the pampiniform plexus
and thus make the mass not obvious. This is especially true in primary varicocele, and absence may be a sign for clinical concern. The testicle on the side of the varicocele may or may not be smaller compared to the other side.
Varicocele can be reliably diagnosed with ultrasound
, which will show dilatation of the vessels of the pampiniform plexus to greater than 2 mm. The patient being studied should undergo a provocative maneuver, such as Valsalva's maneuver (straining, like he is trying to have a bowel movement) or standing up during the exam, both of which are designed to increase intraabdominal venous pressure and increase the dilatation of the veins. Doppler ultrasound is a technique of measuring the speed at which blood is flowing in a vessel. An ultrasound machine that has a Doppler mode can see blood reverse direction in a varicocele with a Valsalva, increasing the sensitivity of the examination.
Recent studies have shown that varicocele is a bilateral disease and the diagnosis of the right side is missed by physical examination and even by ultrasonography.
The examination should be performed by Ultrasonography — color flow doppler performed by highly experienced radiologist that will diagnose varicocele by demonstrating back-flow in the right and in the left spermatic veins.
link between the presence of a varicocele and infertility in males is questionable.
A small prospective study (n=322) however, suggests that varicocele correction aimed at restoring fertility appears to be most appropriate for men whose infertility extends beyond 2 years. These data suggest that varicocele correction at 1 year of infertility does not result in a significantly higher pregnancy rate than that achieved by men with uncorrected varicocele.
(groin), retroperitoneal (abdominal), and infrainguinal/subinguinal (below the groin). Various other techniques may be used. Ice packs should be kept to the area for the first 24 hours after surgery
to reduce swelling. The patient may be advised to wear a scrotal support for some time after surgery.
Possible complications of this procedure include hematoma
(bleeding into tissues), hydrocele
(accumulation of fluid around the affected testicle), infection
, or injury to the scrotal tissue or structures. In addition, injury to the artery that supplies the testicle may occur.
In the Gat-Goren nonsurgical method for treating varicoceles, performed under local anesthesia
, a catheter
is inserted through a vein in the upper thigh. Fluid injected through the catheter selectively closes off the malfunctioning veins, thus enabling the testicular tissues to recover and begin to produce normal sperm in normal amounts. The procedure lasts one to two hours and causes almost no discomfort. The patient can return to his regular routine in about 5 days.
An alternative to surgery is embolization
, a minimally invasive treatment for varicocele that is performed by an interventional radiologist. This involves passing a small wire through a peripheral vein and into the abdominal veins that drain the testes. Through a small flexible catheter
, the doctor can obstruct the veins so that the increased pressures from the abdomen are no longer transmitted to the testicles. The testicles then drain through smaller collateral veins. The recovery period is significantly less than with surgery and the risk of complications is minimised with overall effectiveness similar to surgery, yet with fewer recurrence rates.
Embolization is an effective treatment for post-surgical varicoceles. These are varicoceles that reappear after they have been surgically repaired. The main theory is the presence of redundant gonadal veins that provide collateralization cause the reappearance of the varicoceles. The use of NBCA glues during the embolization is as effective at embolizing these collaterals as coils.
Medical treatment with L-carnitine has some beneficial effect on sperm parameters, but is not as effective as surgery. Micronised purified flavonoid fractions (MPFF) have a beneficial effect on reducing varicocele pain and reducing reflux time of left spermatic vein during the Valsalva maneuver.
An inguinal hernia
can sometimes be misdiagnosed as a varicocele by an untrained eye.
Vein
In the circulatory system, veins are blood vessels that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated blood to the heart...
that is in the scrotum
Scrotum
In some male mammals the scrotum is a dual-chambered protuberance of skin and muscle containing the testicles and divided by a septum. It is an extension of the perineum, and is located between the penis and anus. In humans and some other mammals, the base of the scrotum becomes covered with curly...
draining the testicles. The testicular blood vessels originate in the abdomen and course down through the inguinal canal
Inguinal canal
The inguinal canal is a passage in the anterior abdominal wall which in men conveys the spermatic cord and in women the round ligament. The inguinal canal is larger and more prominent in men.-Site:...
as part of the spermatic cord
Spermatic cord
The spermatic cord is the name given to the cord-like structure in males formed by the ductus deferens and surrounding tissue that run from the abdomen down to each testicle.-Contents of spermatic cord:...
on their way to the testis. Upward flow of blood in the veins is ensured by small one-way valves that prevent backflow. Defective valves, or compression of the vein by a nearby structure, can cause dilatation of the veins near the testis, leading to the formation of a varicocele.
Signs and symptoms
Symptoms of a varicocele may include:- Dragging-like or aching pain within scrotumScrotumIn some male mammals the scrotum is a dual-chambered protuberance of skin and muscle containing the testicles and divided by a septum. It is an extension of the perineum, and is located between the penis and anus. In humans and some other mammals, the base of the scrotum becomes covered with curly...
. - Feeling of heaviness in the testicle(s)
- Atrophy (shrinking) of the testicle(s)
- Visible or palpable (able to be felt) enlarged vein
Cause
The idiopathicIdiopathic
Idiopathic is an adjective used primarily in medicine meaning arising spontaneously or from an obscure or unknown cause. From Greek ἴδιος, idios + πάθος, pathos , it means approximately "a disease of its own kind". It is technically a term from nosology, the classification of disease...
varicocele occurs when the valves within the veins along the spermatic cord do not work properly. This is essentially the same process as varicose veins
Varicose veins
Varicose veins are veins that have become enlarged and tortuous. The term commonly refers to the veins on the leg, although varicose veins can occur elsewhere. Veins have leaflet valves to prevent blood from flowing backwards . Leg muscles pump the veins to return blood to the heart, against the...
, which are common in the legs. This results in backflow of blood into the pampiniform plexus
Pampiniform plexus
The pampiniform plexus is a network of many small veins found in the human male spermatic cord. It is formed by the union of multiple spermatic veins from the back of the testis and tributaries from the epididymis....
and causes increased pressures, ultimately leading to permanent damage to the testicular tissue.
Varicoceles develop slowly and may not have any symptoms. They are most frequently diagnosed when a patient is 15–30 years of age, and rarely develop after the age of 40. They occur in 15-20% of all males, and in 40% of infertile males.
98% of idiopathic varicoceles occur on the left side, apparently because the left testicular vein
Testicular vein
The testicular vein , the male gonadal vein, carries deoxygenated blood from its corresponding testis to the inferior vena cava or one of its tributaries...
connects to the renal vein
Renal vein
The renal veins are veins that drain the kidney. They connect the kidney to the inferior vena cava.It is usually singular to each kidney, except in the condition "multiple renal veins".It also divides into 2 divisions upon entering the kidney:...
(and does so at a 90-degree angle), while the right testicular vein drains at less than 90-degrees directly into the significantly larger inferior vena cava
Inferior vena cava
The inferior vena cava , also known as the posterior vena cava, is the large vein that carries de-oxygenated blood from the lower half of the body into the right atrium of the heart....
. Isolated right sided varicoceles are rare, and should prompt evaluation for an abdominal/ pelvic mass or a kidney cancer.
A secondary varicocele is due to compression of the venous drainage of the testicle. A pelvic or abdominal malignancy is a definite concern when a right-sided varicocele is newly diagnosed in a patient older than 40 years of age. One non-malignant cause of a secondary varicocele is the so-called "Nutcracker syndrome
Nutcracker syndrome
In medicine, the nutcracker syndrome — is a clinically manifest variant of nutcracker phenomenon, renal vein entrapment syndrome, or mesoaortic compression of the left renal vein. It results most commonly from the compression of the left renal vein between the abdominal aorta and superior...
", a condition in which the superior mesenteric artery
Superior mesenteric artery
In human anatomy, the superior mesenteric artery arises from the anterior surface of the abdominal aorta, just inferior to the origin of the celiac trunk, and supplies the intestine from the lower part of the duodenum through two-thirds of the transverse colon, as well as the pancreas.-Location...
compresses the left renal vein, causing increased pressures there to be transmitted retrograde into the left pampiniform plexus. The most common cause is renal cell carcinoma
Renal cell carcinoma
Renal cell carcinoma is a kidney cancer that originates in the lining of the proximal convoluted tubule, the very small tubes in the kidney that filter the blood and remove waste products. RCC is the most common type of kidney cancer in adults, responsible for approximately 80% of cases...
(a.k.a. hypernephroma) followed by retroperitoneal fibrosis or adhesions.
Pathophysiology
The term varicocele specifically refers to dilatation and tortuosity of the pampiniform plexusPampiniform plexus
The pampiniform plexus is a network of many small veins found in the human male spermatic cord. It is formed by the union of multiple spermatic veins from the back of the testis and tributaries from the epididymis....
, which is the network of veins that drain the testicle. This plexus travels along the posterior portion of the testicle with the epididymis and vas deferens, and then into the spermatic cord. This network of veins coalesces into the gonadal, or testicular, vein
Testicular vein
The testicular vein , the male gonadal vein, carries deoxygenated blood from its corresponding testis to the inferior vena cava or one of its tributaries...
. The right gonadal vein drains into the inferior vena cava
Inferior vena cava
The inferior vena cava , also known as the posterior vena cava, is the large vein that carries de-oxygenated blood from the lower half of the body into the right atrium of the heart....
, while the left gonadal vein drains into the left renal vein
Renal vein
The renal veins are veins that drain the kidney. They connect the kidney to the inferior vena cava.It is usually singular to each kidney, except in the condition "multiple renal veins".It also divides into 2 divisions upon entering the kidney:...
at right angle to the renal vein, which then drains into the inferior vena cava.
The small vessels of the pampiniform plexus normally range from 0.5–1.5 mm in diameter. Dilatation of these vessels greater than 2 mm is called a varicocele.
Diagnosis
Upon palpation of the scrotum, a non-tender, twisted mass along the spermatic cord is felt. Palpating a varicocele can be likened to feeling a bag of worms.When lying down, gravity may allow the drainage of the pampiniform plexus
Pampiniform plexus
The pampiniform plexus is a network of many small veins found in the human male spermatic cord. It is formed by the union of multiple spermatic veins from the back of the testis and tributaries from the epididymis....
and thus make the mass not obvious. This is especially true in primary varicocele, and absence may be a sign for clinical concern. The testicle on the side of the varicocele may or may not be smaller compared to the other side.
Varicocele can be reliably diagnosed with ultrasound
Ultrasound
Ultrasound is cyclic sound pressure with a frequency greater than the upper limit of human hearing. Ultrasound is thus not separated from "normal" sound based on differences in physical properties, only the fact that humans cannot hear it. Although this limit varies from person to person, it is...
, which will show dilatation of the vessels of the pampiniform plexus to greater than 2 mm. The patient being studied should undergo a provocative maneuver, such as Valsalva's maneuver (straining, like he is trying to have a bowel movement) or standing up during the exam, both of which are designed to increase intraabdominal venous pressure and increase the dilatation of the veins. Doppler ultrasound is a technique of measuring the speed at which blood is flowing in a vessel. An ultrasound machine that has a Doppler mode can see blood reverse direction in a varicocele with a Valsalva, increasing the sensitivity of the examination.
Recent studies have shown that varicocele is a bilateral disease and the diagnosis of the right side is missed by physical examination and even by ultrasonography.
The examination should be performed by Ultrasonography — color flow doppler performed by highly experienced radiologist that will diagnose varicocele by demonstrating back-flow in the right and in the left spermatic veins.
To treat or not?
Whether or not a varicocele causes infertility is a contentious issue. The recent Cochrane Database Systematic Review of eight randomised controlled trials on this topic suggests that there may be no improvement in fertility after treating a varicocele. The article implies that even the existence of a reliable causalCausality
Causality is the relationship between an event and a second event , where the second event is understood as a consequence of the first....
link between the presence of a varicocele and infertility in males is questionable.
A small prospective study (n=322) however, suggests that varicocele correction aimed at restoring fertility appears to be most appropriate for men whose infertility extends beyond 2 years. These data suggest that varicocele correction at 1 year of infertility does not result in a significantly higher pregnancy rate than that achieved by men with uncorrected varicocele.
Possible treatment
Varicocelectomy, the surgical correction of a varicocele, is performed on an outpatient basis. The three most common approaches are inguinalInguinal
In human anatomy, the inguinal region refers to either the groin or the lower lateral regions of the abdomen. It may also refer to:* Conjoint tendon, previously known as the inguinal aponeurotic falx, a structure formed from the transversus abdominis insertion into the pecten pubis* Granuloma...
(groin), retroperitoneal (abdominal), and infrainguinal/subinguinal (below the groin). Various other techniques may be used. Ice packs should be kept to the area for the first 24 hours after surgery
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
to reduce swelling. The patient may be advised to wear a scrotal support for some time after surgery.
Possible complications of this procedure include hematoma
Hematoma
A hematoma, or haematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This distinguishes it from an ecchymosis, which is the spread of blood under the skin in a thin layer, commonly called a bruise...
(bleeding into tissues), hydrocele
Hydrocele
A hydrocoele denotes a pathological accumulation of serous fluid in a body cavity. It can also be noted as a minor malformation of newborns due to high levels of lead in the mother's blood during pregnancy....
(accumulation of fluid around the affected testicle), infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
, or injury to the scrotal tissue or structures. In addition, injury to the artery that supplies the testicle may occur.
In the Gat-Goren nonsurgical method for treating varicoceles, performed under local anesthesia
Local anesthesia
Local anesthesia is any technique to induce the absence of sensation in part of the body, generally for the aim of inducing local analgesia, that is, local insensitivity to pain, although other local senses may be affected as well. It allows patients to undergo surgical and dental procedures with...
, a catheter
Catheter
In medicine, a catheter is a tube that can be inserted into a body cavity, duct, or vessel. Catheters thereby allow drainage, administration of fluids or gases, or access by surgical instruments. The process of inserting a catheter is catheterization...
is inserted through a vein in the upper thigh. Fluid injected through the catheter selectively closes off the malfunctioning veins, thus enabling the testicular tissues to recover and begin to produce normal sperm in normal amounts. The procedure lasts one to two hours and causes almost no discomfort. The patient can return to his regular routine in about 5 days.
Embolization
Embolization is a non-surgical, minimally-invasive procedure performed by an interventional radiologist and interventional neuroradiologists. It involves the selective occlusion of blood vessels by purposely introducing emboli.-Therapeutic applications:...
, a minimally invasive treatment for varicocele that is performed by an interventional radiologist. This involves passing a small wire through a peripheral vein and into the abdominal veins that drain the testes. Through a small flexible catheter
Catheter
In medicine, a catheter is a tube that can be inserted into a body cavity, duct, or vessel. Catheters thereby allow drainage, administration of fluids or gases, or access by surgical instruments. The process of inserting a catheter is catheterization...
, the doctor can obstruct the veins so that the increased pressures from the abdomen are no longer transmitted to the testicles. The testicles then drain through smaller collateral veins. The recovery period is significantly less than with surgery and the risk of complications is minimised with overall effectiveness similar to surgery, yet with fewer recurrence rates.
Embolization is an effective treatment for post-surgical varicoceles. These are varicoceles that reappear after they have been surgically repaired. The main theory is the presence of redundant gonadal veins that provide collateralization cause the reappearance of the varicoceles. The use of NBCA glues during the embolization is as effective at embolizing these collaterals as coils.
Medical treatment with L-carnitine has some beneficial effect on sperm parameters, but is not as effective as surgery. Micronised purified flavonoid fractions (MPFF) have a beneficial effect on reducing varicocele pain and reducing reflux time of left spermatic vein during the Valsalva maneuver.
Prognosis
Varicocele is usually harmless except in cases of infertility. If surgery is required because of infertility or testicular atrophy, the outcome is usually excellent. Removal of varicocele can lead to normal testicular temperatures and an increased sperm production.An inguinal hernia
Inguinal hernia
An inguinal hernia is a protrusion of abdominal-cavity contents through the inguinal canal. They are very common , and their repair is one of the most frequently performed surgical operations....
can sometimes be misdiagnosed as a varicocele by an untrained eye.
External links
- Sky News - Israeli Male Fertility Breakthrough Offers Hope To Childless Couples
- A revolutionary new treatment can correct varicocele in 85% of the cases Jerusalem Post's Headlines
- Patient UK has a nice patient oriented, but detailed explanation of Varicoceles
- The Royal College of Radiologists has good information on Varicocele Embolisation
- the official site of The Gat Goren nonsurgical method for treating varicoceles