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 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.
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.
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.
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.
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.
Often, varicoceles are not treated. Treatment is offered for males who have:
- fertility problems (problems fathering a child)
- 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.
There are many ways to do varicocele surgery. All involve blocking the blood flow in the pampiniform plexus veins.
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 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.
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.
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:
- 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.