You are in: eMedicine Specialties > Urology > Common Problems of the Testicle VaricoceleArticle Last Updated: Aug 15, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Wesley M White, MD, Chief Resident, Department of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine, University of Tennessee Medical Center Wesley M White is a member of the following medical societies: American College of Surgeons, American Urological Association, Endourological Society, Phi Beta Kappa, and Tennessee Medical Association Coauthor(s): Edward David Kim, MD, FACS, Department of Urology, Associate Professor, University of Tennessee School of Medicine; Joe D Mobley III, MD, MPH, Staff Physician, Department of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine/University of Tennessee Medical Center Editors: Gamal Mostafa Ghoniem, MD, FACS, Fellowship Program Director, Section of Voiding Dysfunction, Female Urology and Reconstruction, Clinical Professor of Surgery, Head, Cleveland Clinic Florida; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Mark Jeffrey Noble, MD, Consulting Staff, Urologic Institute, Cleveland Clinic Foundation; J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center; Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio Author and Editor Disclosure Synonyms and related keywords: varicocele, varicoceles, scrotal varicocele, varicocelectomy, pampinocele, pampiniform venous plexus, spermatic vein, arrest of sperm secretion, male fertility, male infertility, low sperm count, poor sperm function, dilation of the pampiniform venous plexus, testicular vein, antireflux valve, spermatogonia, Valsalva maneuver, sperm production, sperm function, testicular pain, scrotal pain, testicular swelling, scrotal swelling, spermatogenesis, infertility, fertility treatment, male factor infertility, infertility treatment, testicular thermoregulation, stress pattern of semen, poor sperm production, decreased semen quality INTRODUCTIONSection 2 of 12
  A varicocele is a dilatation of the pampiniform venous plexus and the internal spermatic vein. Varicocele is a well-recognized cause of decreased testicular function and occurs in approximately 15-20% of all males and in 40% of infertile males. Understanding the significance of this anatomic abnormality in the infertile patient requires a brief review of the history, background, and current concepts of functional anatomy, as well as the methods and results of surgical repair. History of the ProcedureVaricocele was first recognized as a clinical problem in the 16th century. Ambroïse Paré (1500-1590, the most celebrated surgeon of the Renaissance, described this vascular abnormality as the result of melancholic blood. Barfield, a British surgeon, first proposed the relationship between infertility and varicocele in the late 19th century. Shortly thereafter, other surgeons reported that varicocele is associated with an arrest of sperm secretion and the subsequent restoration of fertility following repair. Through the early 1900s, reports by other surgeons continued to describe the association of varicocele with infertility. In the 1950s, after a report of fertility following varicocele repair in an individual known to be azoospermic (ie, without sperm), the idea of surgically correcting varicoceles as a clinical approach to certain kinds of male infertility gained support among American surgeons. Research continued, leading to many published studies that associated varicoceles with impaired semen quality. In these studies, researchers documented a recurrent pattern of low sperm count, poor motility, and predominance of abnormal sperm forms; this became known as the stress pattern of semen. Although not synonymous or specific to varicocele, the term suggests early evidence of testicular damage. Urologists then began to assess male infertility through the study of sperm, which are evaluated for count, percentage of motile forms, forward movement or motility, and morphology (shape or form); the semen is also evaluated.ProblemA varicocele is a dilatation of the pampiniform venous plexus within the scrotum. Approximately 15-20% of the healthy fertile male population is estimated to have varicoceles; however, 40% of infertile men may have them. How a varicocele impairs sperm structure, function, and production is unknown, but researchers believe it interferes with testicular thermoregulation. FrequencyAlthough varicoceles appear in approximately 20% of the general male population, they are much more common in the subfertile population (40%). In fact, scrotal varicoceles are the most common cause of poor sperm production and decreased semen quality. Varicoceles are easy to identify and to surgically correct. EtiologyVaricoceles are much more common (approximately 80-90%) in the left testicle than in the right because of several anatomic factors, including (1) the angle at which the left testicular vein enters the left renal vein, (2) the lack of effective antireflux valves at the juncture of the testicular vein and renal vein, and (3) the increased renal vein pressure due to its compression between the superior mesenteric artery and the aorta (ie, nutcracker effect). Also of importance is that a one-sided varicocele can often affect the opposite testicle. Up to 35-40% of men with a palpable left varicocele may actually have bilateral varicoceles that are discovered upon examination. A recent study by Gat et al suggests that up to 80% of men with a left clinical varicocele had bilateral varicoceles revealed by noninvasive radiologic testing.1 Varicoceles vary in size and can be classified into the following 3 groups:
PathophysiologySeveral theories have been proposed to explain the harmful effect of varicoceles on sperm quality, including the possible effects of pressure, oxygen deprivation, heat injury, and toxins. Despite considerable research, none of the theories has been proved unquestionably, although an elevated heat effect caused by impaired circulation appears to be the most reproducible defect. Supporting this hypothesis is the fact that a varicocele created in an experimental animal led to poor sperm function with elevated intratesticular temperature. Regardless of the mechanism of action, a varicocele is indisputably a significant factor in decreasing testicular function and in reducing semen quality in a large percentage of men who seek infertility treatment. Although unproved, a varicocele may represent a progressive lesion that can have detrimental effects on testicular function. An untreated varicocele, especially when large, may cause long-term deterioration in sperm production and even testosterone production. If an infertile male has bilateral varicoceles, both are repaired to improve sperm quality. ClinicalA patient with a varicocele is usually asymptomatic and often seeks an evaluation for infertility after failed attempts at conception. He may also report scrotal pain or heaviness. Careful physical examination remains the primary method of varicocele detection. An obvious varicocele is often described as feeling like a bag of worms. Scrotal examination for varicocele should be a facet of the standard urologic physical examination because of the potential for varicoceles to cause significant testicular damage. The presence of a varicocele does not mean that surgical correction is a necessity. INDICATIONSSection 3 of 12
Reasons for surgical correction of a diagnosed variocele include relieving significant testicular discomfort or pain not responsive to routine symptomatic treatment, reducing testicular atrophy (volume <20 mL, length <4 cm), and addressing the possible contribution to unexplained male infertility. A varicocele may cause progressive damage to the testes, resulting in further atrophy and impairment of seminal parameters. The Male Infertility Best Practice Policy Committee of the American Urological Society recommends that varicocele treatment should be offered to the male partner of a couple attempting to conceive when all of the following are present:
In addition, adult men who have a palpable varicocele and abnormal semen analyses findings but are not currently attempting to conceive should also be offered varicocele repair. A scrotal varicocele is the most correctable factor in a male with poor semen quality; therefore, varicocele repair should be considered a viable choice for appropriately selected individuals and couples with otherwise unexplained infertility because varicocele repair has been shown to improve semen parameters in most men and possibly improve fertility; in addition, the risks of varicocele repair are small. The results of treating varicoceles in adolescents are not as clear as the results of treating varicoceles in adults. Although varicoceles first become apparent in adolescence, their natural history and its timeline for the onset of detrimental effects on testicular function remain unclear. Varicoceles occur in approximately 10-15% of the fertile male population, but not all varicoceles impair sperm function, overall semen quality, or fertility. Important determinations to be made regarding varicoceles in adolescents are whether (1) the varicocele is a progressive lesion and (2) early repair of the varicocele would prevent infertility. In 1977, Lipshultz and Corriere suggested that varicoceles were associated with testicular atrophy that was progressive with age.2 They also observed that testicular biopsy specimens taken from prepubertal boys with varicoceles already revealed histologic abnormalities. However, Diamond et al from Harvard have challenged this concept.3 In 1987, Kass and Belman were the first to demonstrate a significant increase in testicular volume after varicocele repair in adolescents.4 Although Kass and Belman noted catch-up growth, they did not study semen parameters. Collecting a semen sample from an adolescent is not always easy; consequently, studying the effects of a varicocele and the benefits of treatment is difficult. The indications for repairing varicoceles in adolescents include the presence of significant testicular asymmetry (>20%) demonstrated on serial examinations, testicular pain, and abnormal semen analysis results. Very large varicoceles may also be repaired; however, in the absence of atrophy, this indication is relative and controversial. Young men with varicoceles but normal ipsilateral testicular volume should be offered follow-up monitoring with annual objective measurements of testicular volume, semen analyses, or both. RELEVANT ANATOMYSection 4 of 12
The testes are the paired male genital organs that contain sperm, cells that produce and nourish sperm (spermatogonia and Sertoli cells, respectively), and cells that produce testosterone (Leydig cells). The testes are located in a sac called the scrotum. The epididymis is a small tubular structure attached to the testes that serves as a storage reservoir wherein sperm mature. Sperm travel through the vas deferens, which connects the epididymis to the prostate gland. The vas deferens is in the scrotum and is part of a larger tissue bundle called the spermatic cord. The spermatic cord contains the vas deferens, blood vessels, nerves, and lymphatic channels. The pampiniform plexus is composed of the veins of the spermatic cord. These veins drain blood from the testes, epididymis, and vas deferens and eventually become the spermatic veins that drain into the main circulation of the kidneys. The pampiniform venous plexus may become tortuous and dilated, much like a varicose vein in the leg. In fact, a scrotal varicocele is simply a varicose enlargement of the pampiniform plexus above and around the testicle. Two other veins, the cremasteric and the deferential, also drain blood from the testicles; however, they are rarely involved in the varicocele process. Image 1 illustrates the basic anatomy. CONTRAINDICATIONSSection 5 of 12
Opinions vary regarding the value of repairing subclinical varicoceles in infertile men, but most experts do not recommend it. In addition, discovery of a varicocele at the time of vasectomy or vasectomy reversal is a relative contraindication to immediate repair. A six-month delayed repair is recommended to allow the development of collateral vessels in order to decrease the chance of vascular compromise to the testicle. WORKUPSection 6 of 12
Lab Studies
TREATMENTSection 7 of 12
Medical therapyA varicocele is an anatomic abnormality that can impair sperm production and function. No effective medical treatments for varicoceles have been identified. While some investigators are evaluating the role of antioxidants for the treatment of elevated levels of reactive oxygen species, this treatment approach is still experimental. Surgical therapyThe primary form of treatment for varicoceles is surgery. Because of the potential to cause significant testicular damage, evaluate the varicocele during the physical examination. The presence of a varicocele does not mean surgical correction is necessary. The ultimate goals of varicocele repair should include occlusion of the offending varicosity with high success, preservation of arterial flow to the testis, and the minimization of patient discomfort and morbidity. Viable options for repair include radiographic obliteration and surgical repair of various approaches. The efficacy of the myriad techniques is nearly equivalent. Therefore, special attention must be paid to the morbidity of the individual procedure and the expertise of the operating surgeon. Preoperative detailsPerform varicocele surgery in an outpatient setting using one of various anesthetics (eg, general, regional, local). A general anesthetic provides maximal patient comfort. Intraoperative detailsThe 3 most common surgical approaches used to correct a scrotal varicocele include the inguinal (groin), retroperitoneal (abdominal), and infrainguinal/subinguinal (below the groin) approaches. With all 3 approaches, all abnormal veins are tied permanently to prevent continued abnormal blood flow (see Image 2). Avoid the vas deferens and the testicular artery during the surgery. The inguinal and subinguinal approaches are those most commonly used by the vast majority of adult urologists and infertility specialists. The familiar anatomy, low morbidity, and high efficacy make these approaches almost ideal. Inguinal ligation is achieved by incising the inguinal canal down to the external inguinal ring. After cord isolation, the testicular artery is preserved and the veins of the cord are ligated and divided. The subinguinal approach is performed in a similar fashion, but access is achieved through an incision at or near the pubic tubercle that obviates the opening of the external oblique aponeurosis. The advantages of subinguinal varicocele ligation, especially with use of magnification, include decreased pain and easier access to the spermatic cord, especially among obese men and those with a history of inguinal surgery. However, at this level, a greater number of veins are present, especially periarterial anastomosing veins, that make subinguinal ligation technically challenging. The use of the microsurgical technique has advanced the surgical treatment of this disorder by allowing optimal visualization. While the approach to cord isolation is no different, the 6-25X magnification facilitates the identification of small anastomosing veins that might otherwise be missed. Furthermore, the risk of testicular ischemia and testis atrophy due to inadvertent ligation of the testicular artery is greatly reduced with this improved visualization. This risk of arterial ligation can be further reduced by using a mini-Doppler ultrasound probe (Vascular Technology, Inc. (VTI) 20-MHz microvascular Doppler) with the use of a topical vasodilator. The retroperitoneal approach offers great proximal control of the spermatic vein near its insertion at the renal vein, this approach may be accomplished laparoscopically. This technique, however, carries a high recurrence rate (nearly 15%) due to inguinal and retroperitoneal collateral veins, failure to ligate fine periarterial veins when the testicular artery is preserved, an inability to preserve lymphatics, and potential hydrocele formation when the artery and vein are ligated en bloc. This approach to varicocele ablation remains popular among pediatric urologists. Percutaneous embolization represents the least invasive means of varicocele repair. The internal spermatic vein is accessed primarily via cannulation of the femoral vein through a retrograde approach with subsequent balloon and/or coil occlusion of the varicocele. The advantages of percutaneous embolization include preservation of the testicular artery and the relatively noninvasive nature of the technique. However, the percutaneous approach can be fraught with troublesome access to the vein, and postoperative complications such as contrast allergies, arterial injury, thrombophlebitis, and coil migration are uncommon but tangible risks. This approach is often reserved for recurrent varicoceles after open surgical repair. Postoperative detailsPatient instructions
Common discomforts and symptoms that do not require medical attention Patients may experience some postoperative discomfort. Complications are rare. Common discomforts or symptoms do not require a doctor's attention and may include the following:
Postoperative complications that require prompt medical attention
Follow-upCheck the patient's semen 3-4 months after surgery. Because spermatogenesis requires approximately 72 days, any effects from the varicocele repair on semen analysis results are delayed. Patient instructions
For excellent patient education resources, visit eMedicine's Men's Health Center. Also, see eMedicine's patient education articles Understanding the Male Anatomy and Testicular Pain. COMPLICATIONSSection 8 of 12
The prevalence of adverse effects following varicocele repair is remarkably low. Hydrocele or increased fluid around the testicles occurs in 2-5% of patients. Successful surgery often increases conception rates in infertile couples. The overall recurrence rate for varicoceles has been reported as high as 10%. Injury to the testicular artery has been reported in 0.9% of microsurgical varicocele repairs. This incidence may be higher when optical magnification is not used for varicocele repair. Because the testis typically has additional arterial supplies from the vasal and cremasteric arteries, testicular atrophy is uncommon (5%) after division of the testicular artery. Smaller atrophic testes may be at greater risk for accidental testicular artery injury because of the smaller size of the artery in these cases. In a patient in whom a varicocele is first identified during a vasectomy reversal, varicocelectomy at the time of the vasectomy reversal is controversial. Delaying the varicocelectomy preserves some venous return in these patients and avoids possible injury to the testicular artery. Consider varicocele repair 6 months later, after new vascular channels form. OUTCOME AND PROGNOSISSection 9 of 12
Following varicocelectomy, approximately 66-70% of patients have improved bulk semen parameters, and 40-60% of patients have increased conception rates. Because human spermatogenesis takes approximately 72 days, the first improvements in semen analysis results are typically not apparent until 3-4 months after surgery. While many of the published studies are retrospective, a randomized, prospective, controlled study by Magdar and associates confirmed that varicocelectomy is an effective treatment for male subfertility.6 Magdar et al studied male counterparts in couples in 2 subject groups, groups A and B. Group A (20 male subjects with varicoceles) was studied for 1 year, and only 2 (10%) men initiated a pregnancy. Male subjects who could not initiate a pregnancy then underwent varicocele repair; within 2 years, 12 (66%) were successful in initiating a pregnancy. Meanwhile, 25 male subjects in group B underwent immediate varicocele repair. Within the first year, 15 (60%) initiated a pregnancy. After 3 years, an additional 4 (16%) subjects achieved pregnancy. Semen parameters improved in all subjects who underwent varicocele repair, regardless of pregnancy occurrence. Semen parameters were unchanged among group A subjects during their 1 year of observation. This important study concluded that varicoceles are associated with reduced fertility and impaired testicular function, while repair improves sperm parameters and fertility rates. In addition, Vasquez-Levin et al recently demonstrated that varicocele repair benefits sperm morphology, even when evaluated using so-called strict criteria.7 Evers and Collins performed a meta-analysis of 7 randomized controlled trials. Because overall pregnancy rates were 21.7% in operated patients and 19.3% (pNS) in control patients, they concluded that varicocele repair did not improve natural pregnancy rates.8 The concerns with this meta-analysis are that inclusion criteria regarding severity of impairment in semen parameters were not uniform, the varicocele diagnostic criteria and grading were inconsistent, and female factors were not mentioned in their overall analysis. The persistent or recurrent varicocele can be repaired microsurgically with significant improvements in sperm concentration, percent motility, and total motile sperm per ejaculate. In addition, as reported by Grober et al, a beneficial effect on serum testosterone levels, testicular volume, and pregnancy rates can be observed.9 The optimal approach to varicocele ligation has not been proven in evidence-based studies. However, based on available experience and reports, the authors recommend varicocele ligation be performed through an inguinal or subinguinal approach with the use of an operating microscope and hand-held microvascular Doppler ultrasound probe. FUTURE AND CONTROVERSIESSection 10 of 12
In 1992, researchers introduced a new micromanipulation technique known as intracytoplasmic sperm injection (ICSI). With ICSI, surgeons inject a single spermatozoon into an oocyte to initiate fertilization and, eventually, a pregnancy. With the success of this technique, some researchers question the need for varicocele repair. Conversely, a cost-analysis study by Schlegel shows the significant cost advantage of varicocele repair over ICSI.10 In addition, varicocele repair has the potential for improving the male factor, rather than using unknown sperm. ICSI also involves in vitro fertilization (IVF), which carries some risk for the female who donates surgically removed eggs. Another current topic focuses on the benefit of varicocele repair in men who are azoospermic or severely oligospermic. Although numerous studies indicate that varicocele repair can improve spermatogenesis in up to one third of azoospermic men, the initiation of spontaneous pregnancy is highly unusual in this population. The remaining two thirds eventually require testicular sperm extraction and IVF-ICSI, even after varicocele repair. Couples must therefore be counseled realistically regarding the benefit of varicocelectomy in this setting. Other concerns focus on the benefit of varicocele repair in infertile men with poor semen quality who have only ultrasound evidence of a varicocele. While opinions differ about the value of repairing subclinical varicoceles in infertile men, most experts do not recommend it. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Article Last Updated: Aug 15, 2007 | ||||||||||||||
