Varicocele: symptoms, causes and treatments

Varicocele tends to be asymptomatic, but early diagnosis and timely treatment prevent the most feared complication: infertility. We explain it to you.

Last update: September 18, 2022

The term varicocele It refers to the dilation of the veins of the scrotum (the skin that supports the testicles). These veins, belonging to the pampiniform plexus, carry deoxygenated blood from the testicles to the heart.

Venous deficiency causes the disorder because blood pools, or returns, instead of circulating out of the area. It is the equivalent of varicose veins of the lower limbs.

Varicocele is usually unilateral, being left-sided in up to 90% of cases. It can also be bilateral. It is more frequent in young men, between 15 and 25 years oldand has a high prevalence, with 15 cases per 100 males.

Varicocele symptoms

As usual, varicocele is usually asymptomatic and the finding is incidental, during a routine physical exam. When it causes problems, it manifests itself with dull pain, decreased testicular volume, the presence of a lump or a feeling of weight at the scrotal level.

How does it cause fertility problems?

Varicocele is a cause of infertility in about 4 to 8 out of 10 men. This is because The pampiniform plexus is responsible for maintaining the proper testicular temperature. for the production and maturation of sperm.

The testicles require a lower basal temperature than the rest of the body for their functions. That is why they are isolated in their scrotal bag.

The pampiniform plexus is responsible for cooling the blood from the testicular artery before it enters the testicles. Its dilation causes overheating of the testicles, with the consequent lower production and maturation of sperm. In this way, the fertility potential is affected.

Varicocele is a cause of sperm death that may be underestimated if it is not considered.

Testicular alteration has other consequences

In addition, due to the same alteration of testicular function, There is a decrease in testosterone production. Although the varicocele is unilateral, the increase in temperature affects both sides.

The decreased production of testosterone inhibits the development of the testis while going through puberty. In addition to producing the consequent loss of tissue, which can end in testicular atrophy.

Causes of varicocele

There is no definitive and unique cause of varicocele, but rather, it is considered a multifactorial pathology. Theories are oriented to the absence or deficiency of venous valves, which would allow venous reflux that would form varicose veins.

Similarly, left predominance is associated with a longer testicular vein on that side. Therefore, it has higher hydrostatic pressure. Likewise, the left testicular vein empties into the renal vein at a right angle, which hinders adequate venous return.

It can also be caused by increased blood viscosity, which hinders venous reflux. Or by the presence of masses or lymph nodes that block blood flow.

It is more common for varicocele to occur during puberty. The testicles have an accelerated growth at that time, so they require more blood flow.

Diagnosis is clinical, but can be confirmed with imaging

A physical examination is enough to diagnose varicocele.. At the time of scrotal touch there is usually a sensation of bag of worms.

The person should be assessed in bipedestation (standing) and supine (lying down). Varicocele may not be identifiable by physical examination when it is subclinical. In that case, ultrasound works.

Sometimes it is palpable, but not visible. And it may be palpable with or without maneuvers to increase intra-abdominal pressure. That is, asking the patient to perform the Valsalva maneuver.

It is important to take into account the environmental temperature, since the cold raises the testicles towards the inguinal area, making manual exploration difficult.

If varicocele is suspected and there is no clinical evidence after bilateral manual examination in the supine position, standing and with increased intra-abdominal pressure, imaging studies are required. They must show the reflux of blood. Testicular Doppler echosonography and venography are the most indicated.

Should varicocele always be treated?

They are not usually treated unless they cause pain, abnormal growth of the left testicle, abnormal semen analysis, or fertility problems. Analgesics for pain may be indicated, but surgery is the main way to address those that do require it.

Surgery can be open or laparoscopic. Embolization may also be performed. An attempt is always made to block blood flow in the pampiniform venous plexus.

Complications are rare and include the following circumstances:

  • Persistent or recurrent varicocele.
  • Hydrocele (fluid around the testicle).
  • Inflammation of the epididymis (epididymitis).
  • Damage to the testicular artery.

Recovery is quick after surgery, since the procedure is outpatient. Rest should only be maintained for 10 to 14 days. Semen analysis should wait 3 to 4 months to confirm improvement if there was infertility.

The procedure is successful in most cases, with evidence of improvement in semen quality. However, seminograms should be performed every 3 months for 1 year after the procedure.

The spermogram can determine a recovery of semen quality 3 months after surgery.

Varicocele can be reversible

Early diagnosis, especially during puberty, and its treatment in case of symptoms, avoid serious sequelae, such as testicular atrophy and infertility. That is why a study of sperm, hormonal values ​​and testicular volume should be carried out in all patients suspected of having a varicocele.

The presence of any alteration is a criterion to indicate its definitive surgical resolution.. Currently, the techniques used have few side effects and a high success rate.

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