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VARICOCELE

Dr Barak is highly experienced in the diagnosis of varicocele and  has been assessing and treating this condition as part of the Centre for Male Reproduction and Fertility 
 

A varicocele is a scrotal abnormality defined by elongated, dilated and tortuous veins that drain the testicle. Varicoceles are common, observed in 15% of the general male population, and are presumably an evolutionary consequence of men’s upright posture. Most varicoceles (>80%) occur on the left side and the remainder on both sides. They are generally acquired during puberty.

Several theories have been proposed to explain their occurrence, including poorly functioning valves and increased resistance to blood flow where the varicocele veins drain, creating a “dam-like” effect and increasing venous pressure. They do not cause cancer and are not life threatening, but are simply an anatomic consequence of being human.

Varicocele Symptoms

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FIGURE 1. VARICOCELE (V) IS THE BLUE SET OF VEINS THAT DRAIN BLOOD FROM THE TESTIS TO THE BODY.

Most varicoceles are asymptomatic. However, they can be uncomfortable and cause scrotal pain. This pain is generally mild to moderate, occurs with long periods of sitting, standing or activity and is relieved by lying down. Although it can be uncomfortable before bedtime (after a long day of activity), it generally does not occur upon awakening after a night’s rest. The pain is dull, congestive‚ “tooth ache” like and generally doesn’t refer elsewhere. It is not associated with urination issues or erectile dysfunction; however, it is associated with male infertility. Lastly, when large, a varicocele can cause a clumpy “bag of worms” feel in the scrotum and can be bothersome for this reason as well.


Varicoceles and Male Fertility

Approximately 30-35% of men in Dr Barak’s Fertility practice who are evaluated for infertility will have a varicocele, a much higher rate than that found in the general population (15%). This high prevalence which is also in agreement with the data provided in the literature had led to the intensive study of the relationship between varicoceles and abnormal sperm. The leading mechanism which links varicocele and male infertility is associated with increased scrotal temperature which may decrease the effectiveness of sperm production process and reduce the testicular function ability in general (reduce Testosterone production). The leading theory suggests that increased oxidative stress reduces the fertility of varicocele patients. In addition, there is recent data that shows that sperm DNA fragmentation rates, a measure of sperm quality, can be elevated in men with varicoceles and that varicocele repair can significantly lower these rates. In any case, the semen analysis in varicocele patients can show low sperm count, abnormal sperm movement or both.

 Varicocele Diagnosis

The “gold standard” way to diagnose varicoceles is by physical examination. With a patient in a standing position, palpation of the scrotum by a well-trained physician can reveal a varicocele. Exercise and prolonged standing may also demonstrate a varicocele.

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Varicocele Grading

Varicoceles have been arbitrarily divided into 3 grades based upon physical examination findings Subclinical varicoceles are lesions not detected by routine examination, but are suggested by radiologic or other imaging methods. These lesions are smaller than “clinical” varicoceles and, in the value of varicocele repair of these lesions is unknown. Grades I-III are considered “clinical” varicoceles, as they are found on physical examination alone. It is these lesions that are repaired for issues of discomfort or infertility.

The diagnosis of varicocele can also be made with venography, ultrasound, thermography, scintigraphy and CAT scan or magnetic resonance imaging. Conveniently, venography can be combined with embolization using coils to treat varicoceles at the same time. Doppler ultrasound is less invasive than, and correlates well with, venography and relies on the detection of venous flow within the varicocele.

 

Reasons for Varicocele Repair

The reasons to fix a varicocele include:

  • For correction of male factor infertility

 

  • To raise mildly low testosterone levels

 

  • For varicocele-induced scrotal pain

 

  • An adolescent with a large varicocele and evidence of a smaller testis on the side of the varicocele.

 

Varicocele Repair Methods Compared

The goal of varicocele treatment is to stop the backward flow of blood from the body to the scrotum, and therefore to “cool off” the testicles. To achieve this, veins leading from the testis to the body are tied off or interrupted as completely as possible. There are several ways to treat varicoceles. Surgical or incisional methods are performed in the upper scrotum (subinguinal), groin area (inguinal) or lower abdomen (retroperitoneal). The procedure can also be performed with an interventional radiologist through a procedure called venography and embolization.

 

Highly Effective and Yet Underutilized Treatment Approach

Open surgical ligation, performed by a urologist, is the most common treatment for symptomatic varicoceles. Varicocele embolization, a nonsurgical treatment performed by an interventional radiologist, is as effective as surgery with less risk, less pain and less recovery time.

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Varicocele embolization or catheter-directed embolization: Varicocele embolization (also called catheter-directed embolization) is a nonsurgical treatment performed by an interventional radiologist that is a highly effective, widely available technique to treat symptomatic varicoceles. With this nonsurgical treatment, an interventional radiologist uses catheters and other instruments to shut off blood flow to the dysfunctional vein. Throughout this treatment, the patient is relaxed and free of pain.

Specifically, the interventional radiologist makes a tiny nick in the skin at the groin using local anesthesia, through which a thin catheter is passed into the femoral vein, directly to the testicular vein. Contrast dye is then injected to provide direct visualization of the veins to map out the best location for vein embolization. By embolizing the vein, blood flow is redirected through other pathways.

Surgical ligation: One of the most common treatments is open surgical ligation. In this procedure, which is typically performed by a urologist, an incision is made in the skin above the scrotum down to the testicular veins, which are tied off with sutures. Although most patients leave the hospital the same day, 24 percent of surgical ligation patients are required to stay at the hospital overnight. Patients of open surgical ligation can expect a two- to three-week recovery period.

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Prevalence

  • Approximately 10 percent of all men have varicoceles.

 

  • Among infertile couples, 30 percent of men have varicoceles.

 

  • The highest occurrence of varicoceles is in men ages 15–35.

 

  • 80,000–100,000 men in America may undergo surgical correction of varicoceles each year.

 

Advantages of Catheter-directed Embolization

  • No surgical incision in scrotal area

 

  • As effective as surgery, as measured by improvement in semen analysis and pregnancy rates

 

  • Patients can return to normal daily activities immediately and without hospital admittance; surgery requires several weeks’ recovery and hospital admittance

 

  • The rare patient who has varicoceles on both sides can have them fixed simultaneously through one vein puncture site; surgery on both sides requires two separate open incisions

 

  • No general anesthesia required

 

  • No sutures

 

  • No infections

 

  • Cost effective