A varicocele, or varicose vein hernia, is a varicose enlargement of the testicular vein and venous plexus in the scrotum (testicle) that is the most common cause of infertility in men. Varicoceles are treated surgically or with sclerotherapy (sclerotherapy), which can reverse existing infertility in many cases.
What is a varicocele?
A varicocele (varicose vein hernia) is a varicose widening, lengthening and tortuosity of the testicular vein (testicular vein) and the venous plexus in the testicle and epididymis (known as the pampiniform plexus). About 10 to 20 percent of men, mainly between the ages of 15 and 25, may be affected by a varicocele, which usually does not cause any symptoms. Only in some cases does a varicocele manifest itself in the form of a pulling pain in the testicle and groin area, whereby this occurs particularly during physical exertion. Depending on the degree of severity, a varicocele impairs fertility (infertility) via various mechanisms (including an increase in body temperature in the area of the testicle) and is the most common cause of infertility in men, although surgical removal or sclerotherapy of the varicocele can restore fertility in many cases.
Causes
In most cases, a varicocele is due to a congenital disorder of the outflow of blood from the testicular vein into the left renal vein (primary varicocele). This results in an impaired functioning of the venous valve in the testicular vein, which in turn leads to an increase in pressure in this blood vessel. The increase in pressure causes the varicose vein-like dilatation of the testicular vein or the entire venous plexus in the testicle, which is characteristic of varicocele. In this case, the disturbance of blood outflow can be caused by a narrowing of the renal vein by the aorta (main artery) or the aortic branches or by an anatomically unfavorable transition of the testicular vein into the renal vein. In addition, tumors may cause an increase in pressure due to their extension, and vascular ruptures or blood clots may cause a disturbance in blood outflow. In both of the latter cases, we speak of symptomatic varicoceles.
Symptoms, complaints, and signs
A varicocele (varicose vein hernia) does not usually cause any symptoms. It is often discovered only by chance during examinations. In some cases, however, symptoms do occur. In individual cases, varicocele herniation can even lead to infertility in affected men. Testicular varicose veins, however, are relatively common. Up to 20 percent of all young men are affected by varicocele. Most often, the varicose veins develop in the left testicle. There they can also be felt manually. In rare cases varicoceles show symptoms, but then they are very characteristic. Typical is a heavy scrotum with a sore feeling. Especially when standing, there may be intense pain in the testicles. Often worm-like swellings are observed on the scrotum, which often become noticeable with increased abdominal pressure during pressing. However, these swellings can also occur without abdominal pressure. Sometimes the affected testicle is smaller because its growth is disturbed by the varicose vein plexus. The varicose veins create a backlog of blood near the testicle, so there is a higher temperature there. Since testicular development and sperm production are very temperature-dependent, the varicocele can lead to reduced sperm production. In extreme cases, even the entire sperm production comes to a standstill, so that the patient becomes infertile. However, since usually only one testicle is affected, fertility is usually preserved in the case of a varicocele.
Diagnosis and course
Varicoceles are usually diagnosed during a physical examination in which the testicles are palpated in different positions (standing, lying, squatting). It is already possible to make statements about the stage. For example, first-degree varicoceles can be palpated as worm-like tangles while standing and simultaneously performing a Valsalva maneuver (abdominal squeeze). In contrast, second-degree varicoceles can be palpated in a standing position without Valsalva maneuver, while dilations of the venous plexus in the third degree are visible through the skin by means of varices (varicose veins).Subclinical varicoceles (early stage), on the other hand, can only be detected by Doppler sonography (ultrasound of vessels) using the Valsalva maneuver. Sonography can also be used to rule out a renal tumor and determine testicular structure and size. A phlebography (X-ray with contrast medium) provides information about the functionality of the venous plexus. If left untreated, a varicocele leads to infertility.
Complications
A varicocele can cause several complications. First, there is a risk that the varicocele will lead to impaired spermatogenesis. This can result in infertility and inability to conceive. Serious disorders of testicular function may also occur if the varicocele is not treated. This is usually accompanied by severe pain, which can be a great burden for the affected person. If the varicocele is caused by a kidney tumor, this can lead to further complications. If treatment fails, kidney failure, metastasis and, in the further course, death of the patient will occur. During surgery, organs and structures in the area may be injured, for example, the vas deferens or urethra. Bleeding, hematoma, and nerve injury may occur. Injury to a testicle also cannot be ruled out. In some cases, a so-called hydrocele occurs, an accumulation of water in the scrotum, which can be associated with pain and dysfunction. If the patient is allergic, there is a risk of allergic reaction to the agents and materials used. Drug interactions from the prescribed medications can also occur, sometimes resulting in serious health complications.
When should you go to the doctor?
Due to its characteristics, varicose vein hernia can occur only in sexually mature boys and men. Often, the affected person remains symptom-free for a long time, that is why a diagnosis is made during a routine examination. In principle, it is advisable to carry out regular health check-ups. This enables early detection of existing diseases and can contribute to timely application of appropriate treatment methods. Abnormalities and peculiarities of the scrotum should be discussed with a physician. If there are complaints during the sexual act or ejaculation, clarification of the cause is needed. In the case of an unfulfilled desire to have children, medical tests should be used to find out what disorder is causing this circumstance. Therefore, a doctor should be consulted if, despite all efforts, pregnancy still does not occur after a few months. If there is an unpleasant body sensation when pressure is applied to the scrotum, the observation should be discussed with a doctor. If the size of the testicles varies greatly, this can be interpreted as a warning signal. Consultation with a physician is recommended to determine if treatment is needed. Pain in the genital area, irregularities in locomotion or impairments in movement patterns should also be investigated. They cause disturbances in everyday life and, in severe cases, can trigger complications that should be avoided.
Treatment and therapy
Therapeutic measures for varicocele depend on the extent and stage of the disease. With increasing symptoms and pathological spermiogram (analysis of the ejaculate), nowadays a so-called transcatheter sclerotherapy is preferably performed to obliterate the varicocele. This treatment method is differentiated between retrograde and antegrade varicocele sclerotherapy. In retrograde sclerotherapy, the inguinal vein is punctured, from where a catheter is inserted via the renal vein to the dilated area of the venous plexus and the sclerosing agent is then injected through the catheter. In antegrade sclerotherapy, a catheter is placed directly into the dilated vein through which the sclerosing agent is injected. Antegrade sclerotherapy is usually performed under local anesthesia, as the affected person should push during the procedure if possible.In addition to these non-surgical procedures, surgical methods are used to treat a varicocele. Here, either the entire vascular bundle (operation according to Palomo) or only the testicular vein (operation according to Bernardi) is interrupted.In both cases, this is done either through an incision in the lower abdomen or laparoscopically (buttonhole surgery) using several small incisions. In the inguinal surgical method, the incision is made directly in the groin and all veins of the spermatic cord are cut off. All the mentioned methods of treatment of varicocele are considered to be equally good in terms of therapeutic success.
Prevention
Because varicoceles are due to impaired blood flow in the testicular vein, which is usually genetic or anatomic, they cannot be directly prevented.
Follow-up
If the varicocele is treated surgically and the procedure is performed on an outpatient basis, the patient cannot drive a car or use any other means of transportation for 24 hours afterward. Machines must also not be operated, and important decisions are better made on another day. After the surgery, it is advisable for the patient to rest in bed for at least one day. Physical rest is also recommended for about 14 days afterwards. Sporting activities must be avoided during this period. For postoperative care, the scrotum should be regularly cooled with ice for the first 24 hours. This procedure can prevent possible bleeding. The staples or sutures that are applied during the surgical procedure usually dissolve on their own. If this is not possible, the stitches are removed by the doctor after about eight days. It is very important to attend the control examinations. After the treatment of the varicose vein hernia, it is recommended to put on elastic underpants, which serve as a support for the scrotum. Alternatively, it is also possible to wear a scrotum holder. Two days after the surgical procedure, the patient is allowed to shower again. After removal of the stitches or staples, he can also take a bath again.
What you can do yourself
Varicocele must be treated by a doctor. Weak varicoceles usually do not require treatment, but they do require diagnosis and observation. Patients should watch carefully for unusual symptoms and consult a urologist if necessary. A larger varicocele must be surgically removed. After such a procedure, rest and bed rest apply. Pain may occur in the first few days after the procedure, which can be relieved by gentle cooling. In consultation with the doctor, the use of natural remedies is also permitted. Cooling remedies, for example calendula ointment or cool overlays with green or black tea, have also proven effective. Accompanying this, attention must continue to be paid to unusual symptoms. Bleeding or pain reactions may occur, which must be clarified by a doctor. If infertility occurs as a result of the varicocele, therapeutic advice is required. Especially men with a strong desire to have children or an active family planning need the support of a specialist to cope with the incision. If necessary, it may also be useful to talk to other people affected. In addition to self-help groups, there are forums on the Internet. Professional reading and seeking alternative options are also important self-help measures after a severe varicocele.