What is varicocele?

Varicocele is a benign condition characterized by abnormal dilatation of the veins of the pampiniform plexus with blood stagnation, which in the long term can cause various complications. It usually occurs on the left since the spermatic vein inserts at a right angle into the renal vein, resulting in increased intravenous pressure, increased risk of valvular dilatation and consequent reversal of flow, i.e., a reflux, to the testis.

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What are the symptoms?

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The symptomatologic picture of varicocele is usually symptomatic pauci; sometimes, in higher grades there may be a sense of weight or dull soreness at the scrotal level with possible involvement of the groin, especially when the patient assumes an upright position for a long period. It may give some discomfort or painful attack from time to time, especially in hot weather, after hard exercise, at the end of sexual intercourse, or after prolonged time in standing. Dilated veins may be visible and easily recognized on palpation by an experienced hand (feeling like palpating a bag of worms); sometimes the affected testicle may be smaller than the contralateral one.

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How is varicocele diagnosed?

 

Varicocele can be diagnosed by a simple uro - andrological examination. The first step is the objective examination, which is performed in orthostasis, since mild degrees may not be appreciated in clinostatic conditions. The physician palpating the pampiniform plexus may feel the sensation of dilated veins as "chicken entrails." This may be accentuated if the patient is asked to perform a ponzamento (Valsalva maneuver) due to reduced central venous outflow. 

The contralateral testis may appear slightly decreased in volume or consistency.

 

Is the clinical examination sufficient for diagnosis?

 

No, the diagnosis should be confirmed and deepened with a simple noninvasive examination: scrotal and sperm vessel color doppler echo in both clinostatism and orthostatism. This is useful to assess: the diameter of the veins and the presence, type, and velocity of venous reflux.

In patients of childbearing age, it is useful to perform a follow-up spermiogram.

 

Why is it important to diagnose varicocele?

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According to scientific evidence, it is the most frequent pathology in the infertile male. It is present in 11.7 percent of the adult male population and in 25.4 percent of men who have an altered spermiogram.

Alterations in the sperm fluid consist of reduced sperm count and motility (oligo- asthenospermia) and increased abnormal forms (teratospermia).

More severe varicoceles can result in the following complications:

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Testicular atrophy. In medicine, the term atrophy refers to a reduction in the mass of a tissue or organ, caused by a decrease in cell volume (i.e., the cells that make up the affected tissue or organ).
Testicular atrophy, therefore, is a reduction in the size of one or both testes. 
In the case of varicocele, the affected testis is obviously the one affected by the problem with the testicular venous vessels.
The precise triggers are unclear. According to the most accepted theory, what causes testicular atrophy would be the stagnation of venous blood at the scrotal level; in this blood, in fact, there are toxins and waste products taken from the newly irradiated tissues, which, by staying for a long time in the scrotum, would result in more or less severe damage to the testicle and a reduction in its volume.
In addition, again due to venous blood stagnation, arterial blood circulation is impeded and insufficient to maintain all the cells in the testis with varicocele.

Male infertility. Like atrophy, male infertility would also appear to be due to blood stagnation in the testicular veins. According to experts, in fact, this would cause an abnormal increase in temperature around the testicles; a temperature increase that, in the long run, impairs sperm formation and sperm movement capabilities.
Although a possible complication, male infertility from varicocele is a very rare occurrence.

 

 

Treatment of Varicocele

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When is it Necessary and Which Techniques are Used

Surgical intervention for resolving varicocele is not recommended for all patients but is reserved for specific conditions:

a. If the patient experiences symptoms such as pain or a feeling of heaviness;

b. Young patients to prevent damage to spermatogenesis;

c. Infertile patients to improve spermatogenesis.

Over the years, various surgical techniques have been described for resolving the condition; currently, the microsurgical ligation of spermatic veins is more commonly employed.

The microsurgical technique (inguinal sec. Goldstein, subinguinal sec. Marmar) is performed through an incision of about 2 cm at the level of the external inguinal ring. The procedure involves freeing the cord and isolating all external spermatic veins, except for the deferential one(s). Subsequently, meticulous hemostasis and layered suturing are performed.

− Performed as day surgery

− Duration: 30 minutes

− Local anesthesia

− Resumption of normal work activities after 48 hours

 

 

Postoperative Complications

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With this technique, there is a persistence/recurrence of varicocele in 1% of cases, rarely a secondary hydrocele may occur, and major complications are generally absent.

Unfortunately, surgical intervention (regardless of the adopted procedure) is not always definitive. In some cases, recurrence may occur, meaning the formation of another varicocele (this time involving the "new" testicular venous vessels to which the return blood circulation has been redirected).

In the event of recurrence, a second surgical intervention is necessary.

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VARICOCELE IN YOUNG INDIVIDUALS

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Even in the absence of evident symptoms, doctors recommend monitoring the size and growth of the testicles periodically in adolescents with varicocele. This is because the affected testicle may grow less rapidly or not grow at all.

In the case of insufficient or slower-than-normal growth, it is advisable to contact your healthcare provider promptly.