Varicocele is a condition where the veins in the scrotum, aka pampiniform venous plexus become enlarged. This enlargement happens when the valves within these veins do not work as they should, causing blood to pool and the veins to dilate.
Varicocele is a common condition, affecting about 10% to 15% of men worldwide. In India, the prevalence of varicocele is higher, with studies suggesting that it affects approximately 20% to 25% of men in the country. The reasons for the higher prevalence in India are not entirely understood, but genetic, environmental, or lifestyle factors play a contributing factor.
What are the different types of varicocele?
Classification of varicocele depends on its clinical characteristics and physical
appearance. The following are the types of varicocele:
Grade 1 varicocele:
Grade 1 varicocele is a small varicocele that cannot be easily seen or felt. The doctor may
diagnose it through a microscope during a medical examination. It may not cause any visible signs or symptoms, and most people with Grade 1 varicocele do not experience any discomfort or fertility problems.
• Grade 2 varicocele:
The grade 2 varicocele is larger than the grade 1 varicocele that one can palpate during a physical examination. The doctor can detect it by gently feeling the scrotum. However, Grade 2 varicocele does not cause visible changes or swelling in the scrotum. Sometimes, it may cause mild discomfort or scrotal pain, but it does not typically affect fertility.
Grade 3 varicocele:
It is the most severe type of varicocele. In this grade, the veins in the scrotum are significantly enlarged and can be both seen and felt. The veins may appear twisted or bulging, and the scrotum may appear swollen. Grade 3 varicocele can cause discomfort, pain, or a heavy feeling in the scrotum. In some cases, it may also cause fertility problems.
What are the symptoms of varicocele?
All varicoceles may not cause apparent symptoms. Many varicoceles are asymptomatic and are discovered incidentally during routine physical examinations or fertility evaluations. However, when symptoms do occur, they can vary in severity and may include the following:
Visible or palpable lump: Varicocele often presents as a lump or swelling in the scrotum. This lump occurs due to the enlarged and dilated veins (characteristic of the varicocele). It may develop anywhere but mainly grows above the testicle. It may be more noticeable while standing or straining. It may feel like a cluster of worms or a bag of soft, squishy tubes.
Scrotal discomfort or pain: Varicocele can cause discomfort or pain in the scrotum area. A person may experience pain as a dull ache or heaviness in the affected area. The discomfort may vary in intensity, ranging from mild to moderate. Numerous factors, such as prolonged standing, physical exertion, or hot weather, can exacerbate the pain. On the other hand, lying down or supporting the scrotum with a jockstrap or similar supportive garment may provide relief.
Testicular atrophy (shrinkage): In some cases, varicocele can lead to testicular atrophy, which is the reduction of the size of the affected testicle. This testicle shrinkage occurs due to increased pressure and impaired blood flow in the affected veins. Testicular atrophy can be associated with infertility or changes in the size and shape of the testicle. However, testicular atrophy is not present in all individuals with varicocele.
Fertility issues: Varicocele can sometimes impact fertility. It may affect sperm quality or quantity due to increased temperature in the testicles and impaired blood flow. Some individuals with varicocele may experience difficulty in conceiving with their partner. According to many studies, not all varicoceles lead to fertility problems. Many individuals with varicocele may live normally and can give birth to a child.
What are the causes of varicocele?
The primary cause of varicocele is the malfunctioning or weakening of the valves within the veins that drain blood from the testicles. These valves are responsible for regulating blood flow and preventing the backflow of blood. When these valves fail to function properly, blood can pool in the veins, leading to their enlargement and the development of varicocele.
The exact cause of varicocele is not fully understood, but several factors may contribute to its development, such as:
Anatomy: The anatomy of the testicular veins and their connection to the renal veins plays a role in varicocele development. The left testicular vein is longer and enters the left renal vein at a right angle, making it more prone to increased pressure and backflow of blood. That is why varicoceles often occur on the left side, although they can also affect the right or both sides. According to a study published in the National Library of Medicine, differences in the course of testicular veins may lead to a higher incidence of left-sided varicocele (>80% of cases).
Faulty valves: Sometimes, the valves within the testicular veins may be structurally weak or not fully formed. This abnormal structure impairs their ability to regulate blood flow effectively. It can result in blood pooling and vein dilation. According to a study published in the National Library of Medicine, the lack or incompetence of testicular vein valves is another factor predisposing to varicocele development.
Increased venous pressure: Factors that increase pressure in the veins can contribute to varicocele formation. These may include physical exertion, prolonged standing or sitting, heavy lifting, and straining during bowel movements. In a study published in science direct, Varicoceles: prevalence and pathogenesis in adult men, researchers suggest that elevated venous pressure may cause varicoceles.
Genetic predisposition: According to some studies, genetics is also a causative factor in varicocele development, as it runs in families. Certain genetic factors may contribute to the weakness of the vein walls or valves, making individuals more susceptible to varicocele. According to a recent study published in the National Library of Medicine, hereditary predispositions to high-grade varicose lesions may exist in teenagers and young adults.
What are the risk factors for varicocele?
According to various researchers, several risk factors may increase the likelihood of
developing a varicocele, such as:
Age: Varicoceles commonly develop during puberty, typically between the ages of 15 and 25. The reason for this age predilection is that during puberty, the testicles are growing, and there is an increase in blood flow to the scrotum. However, varicoceles can occur at any age. Studies have shown that varicoceles often develop during puberty. According to Oster's research, no varicoceles were present in 188 boys aged 6-9. But varicoceles began to appear with increasing frequency as the boys reached 10-14 years, suggesting puberty is the pivotal period for varicoceles. A more recent study by Akbay et al. examined the prevalence of varicoceles in 4052 boys aged 2-19. They found that the presence of varicoceles was less than 1% in boys aged 2-10 but increased to 7.8% in boys aged 11-14, with a further increase to 14.1% in boys aged 15-19. These epidemiological findings suggest that the venous incompetence associated with varicocele primarily occurs during testicular development, which coincides with the onset of puberty.
Genetics: Many studies have found that varicocele has a familial or genetic component. If you have a close family member, such as a father or brother, with a varicocele, the risk of developing the condition may be higher. According to a study published in TAU, adolescents with higher grades of varicoceles were more likely to have fathers who also had varicoceles. Specifically, patients with grade 2 or 3 varicoceles were more prone to have a father with a varicocele than those with grade 1 varicocele. Additionally, patients with grade 2 varicoceles had a higher likelihood of their fathers having undergone varicocele surgery than those with grade 1 varicocele.
Body position and physical exertion: Certain activities or occupations that involve prolonged periods of standing or sitting, as well as heavy lifting or straining, can increase the risk of developing varicocele. These activities can lead to increased pressure in the testicular veins, impairing the normal blood flow and contributing to the development of varicocele.
Testicular abnormalities: Some individuals may have anatomical or structural abnormalities in the testicles that increase the risk of varicocele development. For example, undescended testicles (cryptorchidism), where one or both testicles fail to descend into the scrotum, are associated with a higher risk of varicocele. Abnormal positioning of the testicular veins or abnormal vein structure can also contribute to varicocele development.
Hormonal imbalances: Hormonal imbalances may play a crucial role in varicocele development. Elevated estrogen levels or decreased testosterone levels can affect the veins and lead to vein dilation and varicocele formation. Hormonal imbalances can occur due to various factors, such as genetic factors, certain medical conditions, or medications.
How to prevent varicocele development?
Preventing varicocele may not always be possible since some risk factors, such as genetics, cannot be controlled. However, with the help of some measures, you can reduce the risk or prevent the worsening of varicocele. The following are some steps that can reduce the risk of varicocele development:
Embracing a healthy lifestyle: Indulging in regular physical activity and maintaining a healthy weight to reduce your varicocele risk. Exercise helps improve blood circulation, which can reduce the risk of varicocele. Avoid excessive straining or heavy lifting, as these activities can put extra pressure on the veins in the scrotum.
Adopt proper posture: Avoid staying in one position for too long, especially if it involves sitting or standing. Prolonged sitting or standing can increase pressure on the scrotum veins. You can take breaks and move around regularly to improve blood flow.
Wear supportive underwear: Consider wearing underwear that provides good support, such as briefs or athletic supporters. These types of supportive underwear can help improve blood flow in the scrotum and reduce the risk of varicocele.
Avoid excessive heat exposure: Too much heat can worsen varicocele and affect sperm production. Avoid prolonged exposure to hot environments like saunas or hot baths. Also, avoid wearing tight clothing that traps heat in the groin area.
Practice safe sex: Practice safe sexual habits and use protection during sexual activity. Safe sex practices can help reduce the risk of sexually transmitted infections, which can cause inflammation in the testicles and potentially worsen varicocele.
Regular check-ups: Visit your healthcare professional regularly. Regular check-ups can help detect varicocele at an early stage, allowing for timely intervention if needed.
What are the diagnostic tests for varicocele?
The diagnosis of varicocele typically involves a combination of medical history, physical
examination, and other additional tests. The following are some diagnostic methods for
varicocele:
Medical history: Your doctor will ask questions about your symptoms, such as any pain or discomfort in the scrotum, symptoms duration, and any factors that may worsen or alleviate the symptoms. They will also ask about your medical history, including any previous surgeries or conditions that may be relevant to the development of varicocele.
Physical assessment: The doctors physically examine the scrotum and testicles. They will carefully inspect and feel the scrotum while you are standing and lying down. The doctor may look for any signs of varicocele, such as enlarged or twisted veins, swelling, or a feeling of heaviness in the scrotum. The doctor may use palpation (feeling with their hands) to assess the size, consistency, and any abnormalities in the scrotum and testicles.
Valsalva maneuver: The Valsalva maneuver is a simple technique performed during the physical examination. The doctor will ask you to take a deep breath and bear down as if you are having a bowel movement. This maneuver increases the pressure in the abdomen, which can cause varicoceles to enlarge. The doctor will observe and feel for any changes in the size or prominence of the veins in the scrotum during the maneuver.
Doppler ultrasound: Doppler ultrasound is a non-invasive imaging test that helps visualize the dilated veins in the scrotum and assess the direction and speed of blood flow. It is a commonly used test for diagnosing varicocele and can provide valuable information about the condition.
Scrotal thermography: Scrotal thermography is a test that measures the temperature of the
scrotum using infrared technology. It can detect temperature differences in the scrotum, which may indicate the presence of varicocele. Varicoceles can affect blood circulation and disrupt the temperature regulation in the scrotum, leading to temperature imbalances. Scrotal thermography is a non-invasive and painless procedure that can provide additional information on varicocele diagnosis.
Semen analysis: Your doctor may recommend semen analysis if fertility is a concern. This test involves providing a semen sample, which is analyzed in a laboratory to assess various parameters of sperm quality, including sperm count, motility (movement), and morphology (shape). Varicoceles can impact sperm quality, and semen analysis can help evaluate fertility issues related to varicoceles.
According to the ultrasound, the classification of varicocele includes different grades based on its size and severity. This classification helps doctors understand the condition better and determine the most appropriate treatment options. The following are the grades of varicocele based on ultrasound diagnosis:
• Grade I: This is a subclinical varicocele, which means it is not easily visible on the surface of the scrotum. It can only be detected using ultrasound when the person performs a specific breathing technique called the Valsalva maneuver. During this maneuver, the person forcefully exhales with their mouth closed, which increases pressure inside the abdomen and helps reveal the varicocele on the ultrasound image.
• Grade II: It is visible on ultrasound even without the Valsalva maneuver. The affected veins show some dilation, meaning they are slightly wider than usual. However, the dilation is usually less than 2mm in diameter.
• Grade III: This is a moderate varicocele and visible on ultrasound without the Valsalva maneuver, like Grade II. However, the veins affected by the varicocele are more dilated, typically ranging between 2mm and 3mm in diameter.
• Grade IV: This is a large varicocele. It is easily visible on ultrasound. The veins affected by the varicocele show significant dilation, usually greater than 3mm in diameter.
Frequently Asked Questions
What is a varicocele?
A varicocele is a medical condition characterized by the enlargement of veins within the scrotum. It occurs when the valves in the veins that regulate blood flow from the testicles back to the heart become weak or dysfunctional.
What are the symptoms of varicocele?
Varicoceles may not always cause noticeable symptoms. However, some common symptoms include a dull ache or scrotal pain, swelling or lump in the testicles, and a feeling of heaviness or dragging sensation in the scrotum. In some cases, varicoceles may also lead to infertility or changes in testicular size.
Can varicoceles cause infertility?
Varicoceles can potentially affect fertility in some men. The increased blood flow and blood pooling in the testicular veins can lead to higher testicular temperature. It can interfere with sperm production and quality. However, not all varicoceles lead to infertility, and the impact on fertility varies from person to person.
How is a varicocele diagnosed?
Most of the time, doctors diagnose varicoceles through a physical examination, where the doctor examines the scrotum while the patient is standing and lying. Additional tests, such as scrotal ultrasound or Doppler Ultrasound, may confirm the diagnosis and assess the severity of the condition.
Are varicoceles treatable?
Varicoceles are a treatable condition. The treatment options for varicocele include observation, lifestyle changes, pain management, surgical interventions such as varicocelectomy or embolization, and assisted reproductive techniques. The treatment choice depends on symptoms, infertility concerns, and patient preference.
Can varicoceles come back after treatment?
The recurrence of varicoceles after treatment is possible but relatively rare. Surgical interventions, such as varicocelectomy, have a low recurrence rate. However, it's essential to follow the post-treatment care instructions provided by the healthcare provider to minimize the chances of recurrence.
Can varicoceles be prevented?
It's not always possible to prevent varicoceles, as some factors, such as anatomical malformation or genetic predisposition, are unavoidable. However, adopting a healthy lifestyle, such as regular exercise, maintaining a healthy weight, avoiding prolonged sitting or standing, and wearing supportive underwear, may help reduce the risk or prevent the worsening of varicocele symptoms.
Are varicoceles only found in adults?
Varicoceles can develop in adolescents as well as adults. While the varicocele is more prevalent during puberty, it can occur at any age. The prevalence of varicoceles tends to increase with age.
Do all varicoceles require treatment?
Not all varicoceles require treatment. Sometimes they may need observation without medical intervention, especially when the varicocele is small, asymptomatic, and does not cause fertility issues. Doctors may advise regular check-ups and monitoring in such cases. It is crucial to consult with a healthcare professional, such as a urologist or fertility specialist, for a proper evaluation, diagnosis, and guidance regarding varicocele and its management.
Can varicoceles cause pain during sexual activity?
Varicoceles can sometimes cause discomfort or pain during sexual activity, but it is not a common symptom. If you experience pain, consult with a healthcare professional for further evaluation.
Are varicoceles more common on the left or right side of the scrotum?
Varicoceles are more common on the left side of the scrotum. It is due to the anatomical differences in the veins on each side.
Can varicoceles be treated without surgery?
In some cases, varicoceles may only need non-surgical approaches, such as lifestyle modifications, including wearing supportive underwear, avoiding excessive heat, and managing pain with over-the-counter medications.
Is insurance coverage available for varicocele treatment?
Varicocele treatment insurance coverage can vary depending on your insurance provider and policy. Therefore, check with your insurance company regarding coverage and any pre-authorization requirements.
Can varicoceles be a sign of an underlying health condition?
Varicoceles are typically not a sign of an underlying health condition. However, in some cases, they may be associated with other conditions affecting the blood vessels or testicular health. So, consult with a healthcare professional for proper evaluation and diagnosis of the varicocele.
Can varicoceles increase the risk of testicular cancer?
Varicoceles are generally not associated with an increased risk of testicular cancer. However, if you have concerns about testicular health, discuss your concerns with a healthcare professional for appropriate guidance and evaluation.
Can varicoceles be treated in children?
Varicoceles can occur in children and adolescents. Treatment options for varicoceles in children may include observation, non-surgical management, or surgical intervention, depending on the severity of the condition and associated symptoms.
What is the success rate of varicocele surgery?
Varicocele surgery, such as varicocelectomy, has a high success rate in improving symptoms and fertility outcomes. The success rate can vary and depends on various factors, such as the technique used, the surgeon's expertise, and the patient's overall health.
Can varicoceles be a cause of erectile dysfunction?
Varicoceles are not a direct cause of erectile dysfunction. However, if varicoceles contribute to testicular discomfort or pain, it may indirectly affect sexual function.
Are varicoceles associated with infertility?
Varicoceles can be associated with male infertility. However, not all varicoceles lead to infertility, and the impact on fertility varies among individuals. The increased blood flow and elevated testicular temperature caused by varicoceles may impair sperm production and quality.
Can varicoceles resolve on their own?
In some cases, varicoceles can resolve on their own without treatment. However, if varicoceles cause discomfort, pain, or fertility issues, it is advisable to consult a healthcare professional for proper evaluation and treatment options.
What are the treatment modalities for varicocele?
The treatment and management of varicocele depend on the severity of symptoms, potential complications, and the individual's specific circumstances. The following are
the common approaches to treating and managing varicocele:
Observation: In cases where the varicocele is small, asymptomatic, and does not affect fertility, the doctor may recommend a period of observation without immediate intervention. Regular check-ups, including physical examinations and periodic ultrasounds, will be conducted to monitor the condition and assess any changes in symptoms or fertility.
Lifestyle changes: Certain lifestyle modifications can help manage varicocele symptoms and prevent their progression. These may include: Regular exercise: Regular physical activity can improve blood circulation and reduce symptoms associated with varicocele. Aim for activities that promote overall cardiovascular health, such as walking, jogging, or swimming. Maintaining a healthy weight: Excess weight can pressurize the veins and worsen varicocele symptoms. Adopting a healthy diet and lifestyle to maintain a proper weight can be beneficial.
Avoiding prolonged sitting or standing: Prolonged sitting or standing can contribute to blood pooling in the veins. Take regular breaks, change positions, and avoid crossing your legs to promote better blood flow in the scrotum.
Wearing supportive underwear: Opt for underwear that provides good support, such as briefs or athletic supporters. It can reduce discomfort and improve blood circulation in the scrotum.
Pain management: Sometimes, doctors may prescribe over-the-counter pain relievers, such as nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or acetaminophen, to manage pain or discomfort associated with varicocele. However, always consult with a healthcare professional before taking any medications.
Open Surgical intervention: Your doctor may recommend surgical treatment of varicocele in cases where varicocele causes significant pain, discomfort, or fertility issues.
The surgical procedure for varicocele is Varicocelectomy: It is a surgical procedure performed to ligate or remove the enlarged veins in the scrotum. The surgeon can do it through various approaches, including open surgery, laparoscopy (minimally invasive surgery using small incisions and a camera), or microsurgery (using an operating microscope).
.Non-Surgical (without Cut) intervention for varicocele is Embolization: In this procedure, a vascular interventionist inserts a catheter into a vein, usually through the groin or neck, and guides it to the varicocele site. The surgeon then used small coils or special agents to block the blood flow in the affected veins, causing them to shrink.
What is the road to recovery after varicocele treatment?
The recovery after varicocele treatment depends on the specific treatment modality chosen. Let us discuss the recovery process for the two main treatment options separately:
Surgical Treatment (Varicocelectomy):
Hospital stays: Varicocelectomy and embolization are typically outpatient procedures, meaning you can go home the same day. An overnight hospital stay may be required, especially for open surgery or complex cases.
Post-operative care: After the procedure, the patient may require to follow specific post- operative instructions provided by your healthcare provider. These may include: Rest and limited physical activity: The doctor advises the patient to take it easy for a few days or weeks, depending on the extent of the surgery. Doctors may recommend avoiding strenuous activities, heavy lifting, or exercise during the initial recovery phase.
Pain management: The patient may experience pain, discomfort, or swelling in the scrotum area. Your doctor may prescribe pain medications or recommend over-the-counter pain relievers to manage the discomfort.
Wound care: If you had open surgery, you might have incisions that require care and monitoring. Follow the instructions on how to keep the incision clean and dry to prevent infection. The surgeon may use dissolvable sutures or stitches, which will gradually absorb over time.
Follow-up appointments: Your doctor will schedule follow-up appointments to monitor your progress, assess healing, and address any concerns or complications that may arise.
Recovery period: The recovery timeline can vary and depends on the extent of the surgery and the individual's healing process. It may take several weeks to a few months to fully recover. During this time, your healthcare provider will advise you to resume normal activities as advised by your healthcare provider.
Non-surgical Management:
Post-treatment care: The recovery process very quick for non-surgical management. The
doctor will advise you: Follow any recommended lifestyle changes, such as regular exercise, maintaining a healthy weight, avoiding prolonged sitting or standing, and wearing supportive
underwear. Adhere to any medication or pain management recommendations provided by your
healthcare provider. Attend follow-up appointments to assess the effectiveness of the treatment and address any concerns or changes in symptoms.
Recovery timeline: The recovery period for non-surgical management is generally shorter, and you can gradually resume normal activities within a day, based on your comfort level and the healthcare provider's guidance.
