What are Varicoceles?

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1 What are Varicoceles? A varicocele is when veins become enlarged inside your scrotum (the pouch of skin that holds your testicles). These veins are called the pampiniform plexus. Ten to 15 of every 100 males have a varicocele. It is like getting a varicose vein in your leg. What Happens Normally? The male reproductive system makes, stores, and moves sperm. The scrotum is the sac of skin that holds the testicles (testes). Sperm and the hormone testosterone are made in the testicles. Sperm mature while moving through a coiled tube (the epididymis) behind each testicle. Sperm travel to the prostate from each epididymis using a tube called the vas deferens. When you ejaculate, seminal fluid mixes with sperm in the prostate to form semen. The semen travels through the urethra and comes out the end of your penis. The spermatic cord holds the vas deferens and the Varicocele testicular artery, which brings blood to the testicle. It also houses the pampiniform plexus, a group of connected veins that drains the blood from the testicles. The pampiniform plexus cools blood in the testicular artery before it enters the testicles. This helps keep it at the temperature needed to make sperm. What are Varicoceles? Varicoceles are when the pampiniform plexus veins in the scrotum become enlarged. These veins are like varicose veins in the leg. Varicoceles form during puberty, and can grow larger and easier to notice over time. Varicoceles are more common on the left side of the scrotum. This is because the male anatomy isn't the same on both sides. Varicoceles can exist on both sides at the same time, but this is rare. About 10 to 15 boys out of 100 have a varicocele. Most of the time, varicoceles cause no problems and are harmless. Less often varicoceles can cause pain, problems fathering a child, or 1 testicle to grow slower or shrink. Medical Illustration Copyright 2015 Nucleus Medical Media, All rights reserve

2 What are Signs of a Varicocele? Most males with a varicocele have no symptoms. But varicoceles are a concern for many reasons. Some may cause infertility (problems fathering a child) and slow growth of the left testicle during puberty. Varicoceles may be the cause of fertility problems in about 4 out 0f 10 men who have problems fathering their first child. They may also be the cause of fertility problems in about 8 out of 10 men who have problems fathering a child after their first. Varicocele What Can Cause Varicoceles? Many causes of varicoceles have been offered. The valves in the veins may not work well (or may be missing). If blood flow is sluggish, blood may pool in the veins. Also, the larger veins moving from the testicles towards the heart are connected differently on the left and right side. So more pressure is needed on the left side to keep blood flowing through the veins towards the heart. If blood flows backwards or pools in the veins, that can cause them to swell. Rarely, swollen lymph nodes or other abnormal masses behind the abdomen block blood flow. This can lead to sudden swelling of the scrotal veins. This is often painful. Are Varicoceles Common? About 15 out of 100 men have varicoceles. It's hard to predict which of these 15 will have fertility problems caused by their varicocele. But about 4 in every 10 men tested for fertility problems have a varicocele and decreased sperm movement. There's no link with other defects, race, place of birth, or ethnic group. Although varicoceles are often found in men tested for infertility, 8 out of 10 men who have a varicocele don't have fertility problems. How are Varicoceles Diagnosed? Varicoceles are found through self-exam of the scrotum or during a routine doctor s exam. They ve been described as a bag of worms because of how they look and feel. Urologists often check for varicoceles with the patient standing. You may be asked to take a deep breath, hold it, and bear down while your urologist feels the scrotum above the testicle. This technique is known as the Valsalva maneuver. It lets your urologist find any enlarged veins.

3 Your urologist may order a scrotal ultrasound test. Ultrasound uses sound waves to make a picture of what s inside your body. Signs of varicoceles on ultrasound are veins that are wider than 3 millimeters with blood flowing the wrong way during the Valsalva maneuver. The ultrasound can also show the size of the testicles. These are useful in deciding how to treat teenagers. An ultrasound isn t needed if no problems are felt during the physical exam. How are Varicoceles Treated? Often, varicoceles are not treated. Treatment is offered for males who have: fertility problems (problems fathering a child) pain the left testicle growing more slowly than the right Boys with a smaller left testicle are thought to have a higher risk for fertility problems when they get older. There are no drugs to treat or prevent varicoceles. But pain killers (such as acetaminophen or ibuprofen) may help with pain. When needed, surgery is the main form of treatment. Embolization (briefly blocking the veins) is a non-surgical treatment option. Surgery There are many ways to do varicocele surgery. All involve blocking the blood flow in the pampiniform plexus veins. Open Surgery Open surgery repair is done through a single 1 inch cut. The surgeon may use a magnifying glass or operating microscope to see small veins. The surgery can be done under local or general anesthesia. Laparoscopic Surgery Laparoscopic surgery is done through thin tubes put into your body through a small cut. The surgeon uses a special camera to see inside your body. Laparoscopic surgery is done under general anesthesia. Surgery Results Since surgeons have started using smaller cuts through the muscle for open surgery, healing time and pain are about the same with open and laparoscopic surgery. Problems after either surgery are rare. Problems include: varicocele remaining (persistence) or coming back (recurrence) fluid forming around the testicle (hydrocele) injury to the testicular artery There is a small chance surgery won't correct the problem. In rare cases, injury to the testicular artery can lead to loss of the testicle. Persistence or recurrence of the varicocele happens in fewer than 1 of 10 patients who have surgery. Open surgery done with magnification has a low persistence rate or chance of varicocele coming back. Most of the time, patients return to normal activities after 2 days with little pain. Percutaneous Embolization Embolization is done by a radiologist. A special tube is put into a vein in either the groin or neck. An X-ray is used to check the enlarged pampiniform plexus veins. Then coils or balloons are opened through the tube to block the veins. This halts the blood flow in the pampiniform plexus veins and the varicocele shrinks. Percutaneous embolization is most often done with general anesthesia. It often takes several hours. Some problems are:

4 varicocele remaining (persistence) or coming back (recurrence) the coil moving from where it was placed a chance of infection where the tube was placed This method isn't used at most centers. What Can I Expect after Treatment? Healing after surgery is fast and pain is often mild. You should avoid exercise for 10 to 14 days. You can often return to work 1 or 2 days after surgery. You ll also followup with your urologist. For surgery done for fertility problems, semen analysis is done 3 to 4 months later, when new sperm develop. Healing after embolization is also relatively short with only mild pain. You should avoid exercise for 7 to 10 days after the procedure. You can often return to work 1 or 2 days later. The recurrence rate with embolization is often higher than with surgery. But there are cases where embolization is preferred over surgery. The impact of varicocele repair on fertility isn t clear. Some studies show fertility improves after varicocele repair while other studies don t. Semen quality improves in about 6 out of 10 infertile men after varicocele repair. This treatment should be considered along with other fertility treatment choices. In teens, where the main reason for surgery is slow testicular growth, catch-up growth occurs in 8 out of 10 patients. More Information Frequently Asked Questions What will happen if I choose not to get treated? Not treating a varicocele may result in the testicle shrinking and/or a drop in semen quality. This may lead to fertility problems, though this is rare. The varicocele may, over time, cause lasting harm to the testicle that can't be fixed. If a semen analysis is normal, then it's okay not to get treated. If the semen analysis isn't normal, then action is called for. In some men, the "varicocele effect" on making sperm may get worse over time. Fertility issues may come up years later, even if not seen earlier. My teenage son was diagnosed with a varicocele. Should this be fixed? Treatment of teenagers depends on each case. It's important to discuss options with a urologist or pediatric urologist Varicocele repair in a teen may be considered if there is pain or if 1 testicle is more than 10% smaller than the other. Some families choose repair so they won't have to worry about fertility issues in the future. Semen analyses can be done in older teens to see if repair would help. I'm interested in having children and have no symptoms. Should I have my varicocele repaired? As a rule, varicoceles with no symptoms aren't repaired. Most health care providers don't believe these varicoceles cause health problems if not treated. If there's worry about fertility, semen analysis can be done to see if the varicocele is harming sperm quality. I have pain with my varicocele. What can I do to ease the pain?

5 Supporting the scrotum with a jockstrap or briefs-style underwear can help varicocele pain. Lying on your back helps the varicocele drain, and often eases pain. Taking pain killers (such as acetaminophen and ibuprofen) may also help. You can also talk with your urologist about varicocele repair. I'm thinking about having my varicocele repaired for fertility reasons. How long will I have to wait to see if my semen quality improves? Semen analyses are often done every 3 to 4 months after the procedure. Improvement is often seen within 6 months, but might take a year. I found a lump on my scrotum during a self-exam. Should I worry? Abnormalities in the male reproductive tract may show up as a mass in the scrotum. Masses could be nothing to worry about and have little effect on your health. Or they could be a sign of life-threatening illness. It's important to find out what is causing your mass. For example, testicular cancer is cause for concern and calls for prompt action. It's important to seek medical attention when you find any lump or bump in your testicle.