Varicoceles are distended, enlarged testicular veins that may feel like a bag of worms in a man’s scrotum. Varicoceles can occur on one side within the scrotum or on both sides. They usually appear during or soon after puberty but they can occur at any time.
Varicoceles can become larger and more symptomatic over time. They are more common on the left side of the scrotum, as the normal male anatomy is predisposed more for left varicocele formation than right.
Approximately 15 to 20 percent of men have varicoceles.
A plexus or collection of veins collect blood from the testicles and deliver it back to the heart.
Both testicles have a spermatic cord that hold them up and within the spermatic cords are nerves, arteries and veins. Veins have valves that allow blood to flow in one direction back to the heart. If the valves in the veins, that prevent backflow of blood, are not working properly then blood in the testicular vein backs up and forms a varicocele.
There is a grading system that is used to characterise varicoceles and aid in determining, along with other parameters, whether treatment is needed.
Most men with low-grade varicoceles will only complain of a dull pain in the affected side of the scrotum, with the pain sometimes radiating to the lower abdomen on the same side. Pain usually gets worse with activity and is relieved partially at rest.
Higher grade varicoceles could cause persistent severe pain even at rest that negatively affects the quality of life of the afflicted men. Varicoceles may lead to more severe pain with thrombophlebitis, which occurs with inflammation and clotting of blood within the testicular veins. Up to 50 percent of varicoceles on one side will eventually lead to the diagnosis of varicoceles on both sides.
Varicoceles that cannot be felt in the scrotum by a urologist can be diagnosed with imaging such as with an ultrasound. The patient may be asked to bear down and strain during the ultrasound study to lead to more prominent distension of the varicocele if it is present.
Varicoceles are not life-threatening, but very rarely, particularly in older men, may occur secondary to a kidney cancer or an abdominal mass that might be cancerous.
Varicoceles and male infertility
A varicocele could affect the testicular function and temperature. Sperm are produced by the testicles.
Sperm production and the quality of sperms produced could be negatively influenced by an increase in testicular temperature potentially caused by some varicoceles. The back flow of blood in the testicular veins could lead to a reduction in the oxygen supply to the testicles and impair sperm production.
Forty percent of men diagnosed with infertility have one or bilateral varicoceles. Fifteen percent of men with a varicocele are found to have some form of male infertility; thus 85 percent of men with a varicocele are fertile.
Varicoceles and low testosterone
A groundbreaking 2011 scientific research study published in the British Journal of Urology, determined that varicoceles could potentially interfere with the production of the hormone testosterone. The New York hospitals based research study involved 325 men with varicoceles and 510 men without varicoceles. The study showed conclusively that men with varicoceles had significantly lower testosterone levels than men without varicoceles. Following varicocele surgery repair, 70 percent of men in the research group had a significant increase in their testosterone levels.
Low testosterone in men could lead to fatigue, loss of muscle mass, sexual dysfunction, increased fat production and weakening of bones amongst many other negative health consequences.
Low testosterone could potentially have many causes that are unrelated to varicoceles.
Many men with varicoceles will maintain normal testosterone levels throughout their lifetimes even without treatment of their varicocele, but some men will have very low testosterone levels due to a varicocele and will need treatment of their varicocele.
Treatment options for varicoceles
Pain reducing one’s quality of life; reduction in the size of the affected testicle; varicoceles leading to male infertility with abnormal sperm parameters shown on two separate sperm analysis or low testosterone secondary to varicoceles may prompt treatment for varicoceles.
Not all men with a varicocele require any treatment.
Minimally invasive laparoscopic outpatient ligation varicocele surgery with the use of small keyhole incisions in the abdomen with the introduction of a camera and small instruments into the abdomen. This minor surgery requires a minimal recovery period.
Varicocele embolisation is another outpatient management option that involves minimally invasively introducing small coils through a vein in the groin, and blocking the veins in the abdomen that feed the varicocele.
Outpatient microsurgery or open surgery is an option that involves a groin or lower abdominal approach to ligate the varicocele, during regional or general anesthesia.
A fourth varicocele outpatient management option involves using a sclerosing agent or liquid embolic agent to block the testicular veins involved in forming the varicocele.
Causes of scrotal and testicular pain
Varicoceles are one of many possible causes of scrotal pain. Hydroceles are an increased accumulation of fluid around the testes. Spermatoceles are fluid filled cysts around the testicle. Epididymal cysts are fluid filled structures of varying potential sizes that are formed within the epididymis, the tissue appendage attached to the testicle. None of these conditions are life threatening or precancerous but they could possibly cause significant pain.
Infection of the testicle or epididymis on either side or bilaterally would lead to pain and swelling.
Pain may radiate to the scrotum or testicles from elsewhere such as in the case of kidney stones or an infection of the prostate.
A hernia may involve the scrotum and present with swelling within the groin and scrotum that usually increasing in size during exertion.
Testicular cancer usually presents as a painless, firm increased size in the affected testicle or as a testicular mass.
Severe testicular pain in boys and young men could be secondary to testicular torsion which is a surgical emergency, requires untwisting of the testicle so that the blood supply is returned.
Ignoring testicular torsion for more than six to 12 hours could lead to the death of the testicle.
Boys and men should routinely do self examination of their scrotum and testicles during a shower or bath.
Any pain or swelling in the testicle or scrotum should lead to an evaluation by a physician or urologist.
• Dr Greggory Pinto is a board certified Bahamian urologist and laparoscopic surgeon. He has trained in Germany, South Africa and France, and is a member of the European Association of Urology.
Published: January 26, 2021