WHAT IS VARICOCELES? CAN IT BE TREATED?
First, a little background on how the blood flow works and its relation to varicoceles. Every part of the body needs oxygen. Blood carries oxygen to various parts of the body through arteries. Arteries have muscular walls that pump the blood away from the heart. Veins are the channels that bring the blood back to the heart, and they do not have thick, muscular walls. Their walls are fairly thin, and the blood in them moves more passively. It is pushed back toward the heart through the pressure of the blood being pumped away from the heart and the movement of the muscles and other structures surrounding the veins pushing against the vein walls.
Interspersed along the veins are a series of one-way valves. These valves allow the blood to flow toward the heart but stop the blood from "slipping" backwards. (They operate like “flap-valves.”) If these valves are not working properly, blood will flow backwards and, because of gravity, the blood will collect in the most dependent (lowest) part of the pathway. In people who have large varicose veins in their legs, the valves in the veins in their legs are not functioning properly and the blood is actually pooling in their legs. Because of this, they will find that after standing for long periods of time, the blood has collected in their legs, giving them a heavy, dragging feeling. Men with varicoceles may notice a heavy, dragging, aching feeling in the scrotum ("ball sack") at the end of the day. There, too, the valves in the veins that drain the blood from the testicles (the internal-spermatic veins) are not functioning properly and allow the blood to collect, and the veins to swell.
When, where, and why do varicoceles develop?
Varicoceles most commonly develop during adolescence when the testes grow dramatically and therefore need more blood delivered to supply the increased need for oxygen and nutrients. Since more blood is going into the testes, there is also more blood draining away from them. If the valves are not functioning properly, the extra blood cannot be handled by the veins, and the blood pools in the scrotum.
Of those men who have varicoceles, forty-five percent have varicoceles on both sides; fifty percent have a left-side varicocele; and five percent have a varicocele on the right side alone.
Why these valves are not functioning properly is not known. However, there does seem to a genetic component to varicoceles. If large varicoceles develop in a man after adolescence, he must be examined to make sure that there is no tumor in the abdomen pushing and compressing the veins, making the blood unable to properly flow back to the heart.
Why a varicocele may be a problem.
Varicoceles may cause any of the following: testicular damage, infertility, decreased testosterone, pain, cosmetic embarrassment .
Varicoceles may cause damage to the testicles; they may not grow appropriately. This damage is progressive, often worsening over time. If an adolescent has a one-sided varicocele on the testis on that side may not develop as much as the other side and may be significantly smaller. This is a serious consideration because smaller testes generally produce significantly less sperm and testosterone than normal-sized testes.
If the varicocele is repaired during adolescence, the testis may experience catch-up growth and normalize in size and testosterone production. Then the varicocele will have no permanent effects on testicular size or sperm and testosterone production.
If it is repaired at a later age, the testis will not improve in size, though it may improve in sperm and testosterone production. However, there will not be as much improvement as if the varicocele(s) had been repaired earlier.
Varicoceles may cause infertility through a significant decrease in the quality and quantity of the sperm. Fifteen percent of all men have varicoceles. (This was measured by examining military recruits, who represented a good cross section of men mostly before they had tried to father children.). However, forty percent of men who are experiencing “primary infertility” (have never fathered a biological child) have varicoceles.
Eighty percent of men with secondary fertility (they have fathered at least one biological child, but are not currently able to do so) have varicoceles. This may be due to the fact that varicoceles cause progressive damage to the testicle and a progressive decrease in the quality and quantity of sperm produced.
The testes, besides making sperm, also makes testosterone, the main male hormone. Testosterone is responsible for a man’s secondary sex characteristics (i.e., increased muscle mass and tone, level of sexual interest, body hair). Varicoceles can damage the cells that make testosterone as well as suppressing their function and may lead to a decreased overall testosterone level.
On average, a man’s testosterone level is increased by 100 ng/dL after varicocelectomy. This has obvious implications for a man’s health, well being, muscle mass, erections, libido etc.
Varicoceles may cause discomfort leading to a heavy, dragging feeling in the scrotum. It is usually worse with standing, lifting, and straining. If a man has this classic pain and a large varicocele, he will usually have significant improvement in his pain after surgery. However, if the pain is not classic, only 50% of the men will feel better post-operatively.
Many men and boys have quite large varicoceles that they can see and feel themselves. Often the entire side of the scrotum with the varicocele hangs much lower than the other. The veins may be seen from outside, and the overall shape of that side of the scrotum can be much different. Adolescent boys, in particular, are more often bothered by asymmetry and other cosmetic issues associated with a varicocele. Shame and embarrassment may make them uncomfortable with their bodies, both in private and when undressing in front of anyone else.
How do varicoceles cause damage?
Increased temperature of the testicles
The testicles are located in the scrotum, which effectively regulates their temperature. They are maintained at a temperature slightly below body temperature. (This is probably why they are located outside the body rather than inside the body where they clearly would be better protected). In cold weather, men may notice their testicles move close into the body as the muscles in the scrotal wall tighten. In warm weather, the muscles relax and lengthen, allowing the testicles to hang away from a man’s body and cool down.
Some babies are born without their testicles having descended into their scrotum. They are trapped somewhere in their bodies and constantly exposed to body temperature. This is so harmful for the testicles that if they remain there past puberty, they will stop producing sperm altogether and have a higher chance of developing cancer. Therefore, if a boy’s testicles do not descend into the scrotum by the time he is 12 months old, they should be surgically brought down and placed into the scrotum.
Varicoceles are a group of dilated veins filled with blood, which surround the testicles. The blood is at body temperature, and if the testes are near these veins, they will be kept at a higher temperature than is beneficial for them. Even if a man has a varicocele only on one side, the whole scrotum is warmed by the blood and both testicles can be negatively affected.
In general, larger testicles make more sperm and testosterone than smaller testicles. In men who have a large one-sided varicocele that has damaged the testis on one side, making it smaller, the small testis may be contributing significantly less sperm and testosterone to the total than the normal one. However, even in the normal one, production of sperm and testosterone is lower. The varicocele is not only damaging the testis on the side where it is found, but also suppressing the sperm production on the opposite (better) side.
When a varicocele is repaired, the blood is no longer able to flow back into the scrotum. This affects not only the testes on that side, but also the opposite side. With this normalization of temperature, there may be some dramatic improvement in sperm production. It is likely that this improvement comes mostly from improved production in the larger, better testicle.
Increased waste products back-flowing into the testicles
The veins draining the testicles connect into larger veins. On the left side, they drain into the kidney vein, which is draining blood from the kidney. The blood from the kidney carries waste products, which may then drain backwards into the scrotum and collect there. This may negatively affect sperm production.
It used to be thought that a varicocele would result in a stress pattern that would appear in the semen analysis (i.e., a decreased percentage of moving sperm or sperm with abnormally shaped heads). Recent studies conclude that varicoceles affect virtually all of the parameters in a semen analysis (i.e., the concentration, motility, forward progression, and morphology). The varicoceles also affect the functioning of the sperm, although this cannot be tested by a routine semen analysis. Very specialized testing of the sperm functioning may be performed, although this is expensive and its use is debated.
Many boys and men know they have a varicocele because they can feel the mass of dilated veins in the scrotum. This feels like a sack of worms or spaghetti. These men have larger varicoceles.
They may also notice that the testicle is smaller on that side. Interestingly, the scrotum on the varicocele side may look larger, because there are so many veins there. However, when the testicle itself is felt, it is smaller than the one on the other side. They may also notice that they have discomfort in that testicle or side of the scrotum.
During a physical examination a physician may diagnose a varicocele. It can most clearly be felt when a man is standing and again, it will feel like a bag of spaghetti. It may disappear when a man lies down (as the weight of the blood and the veins is no longer pushing down past the malfunctioning valves into the scrotum). In a standing position, the man may also be asked to bear down (like he is having a bowel movement). The physician may feel an impulse when the blood pushes backwards (because of the increased pressure inside the abdomen) into the scrotum.
To confirm varicoceles, sophisticated tests are often used:
- A doppler stethoscope will amplify the sound of blood moving past it. At rest, only the pumping of the artery should be heard. The blood flow in the veins is so slow that no sound can be heard. When the patient pushes down, more blood flows backwards into the scrotum and can be heard as a rushing sound.
- The duplex ultrasound is currently considered the best non-invasive way to identify or confirm the presence of varicoceles. The duplex ultrasound has two parts.
First a thorough ultrasound of the testis is performed. The diameter of the veins can be measured. Other abnormalities may be identified. Almost one third of men with infertility had an abnormal finding on the ultrasound that was not suspected during the physical examination.
The second part of the ultrasound evaluation measures the blood that flows past the probe when the patient pushes down. This blood flow confirms the varicocele. This blood flow can actually be both visualized in color and heard.
There are several ways to fix a varicocele. Fortunately, studies show, with an unusual degree of unanimity, that there is one best way. This is the microscopic sub-inguinal varicocelectomy with ultrasound guidance. This can only be performed by a urologist specializing in fertility and microsurgery.
Microscopic sub-inguinal varicocelectomy with ultrasound guidance
What does this mean, and how is it done?
- Sub-inguinal refers to the location of the incision. This single incision is about one inch above the top of the penis and one inch to either side. If both sides are being operated on, two incisions are made. The scars will later be covered by pubic hair. This is where the spermatic cord (the bundle carrying the vas deferens, the testicular arteries, the veins, the lymphatics, and the muscles) leaves the abdominal wall. What’s important about making the incision here is that the abdominal muscle can be avoided and that means much less postoperative discomfort and significantly reduced healing time.
- Microscopic means that an operating microscope is used. This large microscope stands above the patient, and the doctor performs the delicate part of the operation while looking through it. This allows the surgeon to clearly see all the veins that need to be severed, as well as the arteries and the lymphatics, which drain fluid from the space between the testes and the surrounding sac, to be avoided and not severed.
- Ultrasound means that a small ultrasound probe can be used during the procedure to identify one or more arteries to be spared from damage. As can be imagined, there is more improvement post surgically when the blood flow to the testes is not compromised during the surgery.
In this approach, a patient is almost always sedated, asleep, but not intubated, which is safer for the patient. While sleeping, a local anesthetic is injected into the area. An incision of about one to one and a half inches is made in the numbed area. The spermatic bundle (cord) is located, grasped, and brought out of the patient’s body. Using the microscope, the layers of muscle surrounding it are stripped away. Often several arteries are identified, usually with the use of the ultrasound, and a tie loosely placed around it for identification. The veins are then sequentially located and severed. The cord is then placed back into the patient’s body and the tissues are closed, layer-by-layer. The skin is generally closed with a plastic surgery stitch; the stitches are placed under the skin so that they need not be removed later.
There are lots of advantages associated with this method, there is little discomfort associated with it and the recovery time is fairly quick. During the procedure, the patient feels almost nothing; in virtually all cases, the patient completely sleeps through the procedure. The anesthesiologist can administer sedatives and an appropriate dosage of pain medication.
In terms of recovery there may be some discomfort, swelling, and bruises for several days afterward. Almost all men go back to work after two to three days. Studies have shown that after this type of varicocelectomy, men use less pain medication than most people use after a typical dental procedure.
An alternate method of varicocele surgery is called an inguinal varicocelectomy. Although most infertility specialists use the microscopic sub-inguinal approach, a varicocelectomy is usually performed by a general urologist. In this case, the incision is made just like a hernia incision. The abdominal muscles that cover the varicocele are cut at the point where they leave the abdomen. The cord is exposed. Then, using the naked eye or magnifying lenses worn as glasses, the veins are cut.
The incision is longer than a sub-inguinal incision. It also is higher, making the scar visible above the pubic hair. Because the abdominal muscles are cut, the postoperative pain is significantly increased and the healing process takes longer.
If the microscope is not used, it is harder to see and spare the arteries and lymphatics or to see and sever all of the necessary veins. This means that the arteries bringing blood to the testicle are also usually not spared and thus there is not as much improvement in the sperm quality and a higher chance of damage to the testes. Because it is harder to identify and sever all of the veins there is a higher incidence of failure (5% to 15%). Because it is harder to identify the lymphatics and leave them, rather than tying them with the veins, the formation of hydrocele, a collection of fluid around the testicle, is significantly increased (3% to 30%).
The retroperitoneal approach to varicocelectomy involves an even higher incision to sever the veins further up. This leaves a more obvious and unusual scar. It also involves cutting abdominal muscles, which increases postoperative pain and recovery. The arteries cannot be preserved. It has a failure rate of 15% to 25% and a risk of hydrocele formation of approximately 7%.
You can also choose to have a varicocele repaired laparoscopically. Here, the patient must be placed under a general anesthetic. A catheter (tube) is placed into the bladder in order to allow the urine to drain out so that the bladder does not get in the way of the procedure. A small incision is made under the umbilicus (belly button) and the abdomen is filled with air. The needle is replaced with a larger, bored trocar (sharp tool) and a sheath so that the camera can be placed in the abdomen. Under vision, an additional two incisions are made in the abdominal wall and two working instruments are placed into the abdomen. The bundle carrying the vein and arteries is identified. At this point, this bundle is transected. Care is taken not to transect the vas deferns accidentally.
This procedure is not generally recommended because it requires that the patient be under a general anesthesia, that a Foley catheter be inserted, and that instead of an incision outside the abdominal wall three incisions in the abdominal wall must be made. There are also inherent risks with laparoscopy that are greater than those with the small open procedure done with microscopic varicocelectomy. Recurrence rates are significantly higher, as are the rates of hydrocele formation.
A procedure may be done by an interventional radiology. A small incision is made in the groin. A long tube is then inserted into the leg vein. It is snaked, under x-ray guidance, up into the vena cava (the body’s largest vein), and then into the main vein that drains the kidney. A coil or substance is then placed so that the vein is blocked.
Unfortunately, it has a rather high failure rate, because many veins that may cause the varicocele drain into other places, and are not blocked by this procedure.
It is quite useful if there is significant scar tissue where an incision would be made, usually from previous surgeries in the area. A good example is if a man has already had a procedure to bring down an undescended testicle on that side.
How successful is a varicocelectomy?
Success rates of varicocele treatments can be measured in terms of resulting pregnancy rates: 60% of men will establish a pregnancy within one year of varicocelectomy. Seventy-two percent of men will do so after two years. This compares to 16% of men whose partners will conceive without undergoing a varicocelectomy during the same period.
Success rates can also be measured by change in semen analysis results. Sixty-five percent of men will show a significant improvement in the semen analysis within 12 months. A significant change is defined as a doubling of the total motile count. The total motile count is the calculated number of moving sperm that the man actually ejaculates.
Men with larger varicoceles will show more significant improvement. In these men, 69% will have a three-fold improvement in the total motile count in the ejaculate.
Many men have a large varicocele on one side and a small varicocele on the other side. An interesting study addressed whether, in these cases, both varicoceles should be repaired or if just the larger one should be. Sixty-five percent of men with bilateral (two sided) varicoceles with a small varicocele on one side and a large varicocele on the other chose to have both varicoceles repaired. This group showed a 104% increase in the total motile count. Twenty-six percent of the men decided to have surgery only on the left side and they showed an average improvement of 45% in the total motile count. In general, even if only a small varicocele is found on the opposite side of a large varicocele, it is recommended that they both be repaired.
A few more numbers from a different study: This one looked at 25 men older than 45 years of age and showed an average preoperative concentration of 12.7 million/cc, a motility of 29.6%, and a normal morphology (shape) of 24.4%. Postoperatively, the average concentration was 20.3 million/cc. The average motility was 44.7% and the average normal morphology was 30.7%. It would appear that even older men with long standing varicoceles will show significant improvement from a varicocelectomy.
It takes 78 days from the beginning of a sperm’s development until it is ready to be ejaculated. This is a continuous process very much like an assembly line. At any given time, there should be millions of sperm at all stages of development.
So it almost always takes a minimum of four months to see any significant improvement in the semen analysis after a varicocelectomy. The semen analysis may continue to improve for up to two years. If, however, there has been no improvement within six months, other options should be simultaneously considered.
Performing a varicocelectomy does not in any way negatively affect the sperm. So, couples may continue to try to achieve a pregnancy during the time they are waiting for improvement.
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