What is a varicocele?

A varicocele is a medical disorder that describes a collection of dilated or enlarged veins in the scrotum. There are many small veins that drain blood away from the scrotum into the blood circulation. Sometimes these veins get blocked and congestion of blood results. Over time, these veins become engorged and are known as Varicoceles. Varicoceles are the same thing as varicose veins on the legs. When Varicoceles become large, one may be able to feel them – this sensation is often described as a “bag of worms”

Which scrotum is most affected with Varicoceles?

Varicoceles can occur in both scrotums. but generally are more common on the left side.

Why does a varicocele develop?

Blood flow in veins occurs only in one direction. To prevent back flow, veins have tiny valves. When these valves become defective or fail to close properly, blood starts to pool and collect downstream. This leads to congestion of veins leading to Varicoceles. It is believed that defective valves are the most common cause of Varicocele in young males.

The small veins from the scrotum drain into larger veins of the body. Often, if there is a cancer or a mass, which compresses the large veins, this can lead to engorgement of small veins downstream. In the left scrotum, cancers of kidney can often cause development of Varicoceles. This is more common in middle-aged males.

Does varicocele surgery improve fertility?

There is absolutely no direct correlation between the presence of a varicocele and infertility. There is no doubt that about 40% of individuals who undergo investigation for infertility have been found to have varicoceles. But one has to know that there are many more individuals with varicoceles who go on to have normal sperm and have satisfactory pregnancy with their spouse. There are also many men who undergo varicocele surgery and yet fail to have normal sperm counts.

The questions remains, “what should one do with varicoceles”. There is no question that incidentally discovered varicoceles or varicoceles that produce no symptoms can be safely observed. All the data about testicular atrophy and decline in sperm counts are unproven and hypothetical facts put out by unscrupulous surgeons. Many men live their entire lives with varicoceles and do so without any undue problems.

Varicoceles continue to generate controversy among fertility experts. Despite conflicting evidence from various clinical studies, all the trials still recommend the surgical treatment of clinical varicoceles in men with infertility. However, it is incumbent on the surgeon to discuss the pros and cons of surgery for varicocele. A second opinion is not always a bad idea.

What are treatment options for varicoceles?

There is a lot of debate whether varicoceles require any treatment. No medical therapies are available for either treatment or prevention; however analgesics (pain medications) may alleviate associated pain when present. Some doctors claim that no treatment is required. Others claim that treatment may benefit individuals who are infertile and have symptoms. The treatment involves removal of the vein mass which is supposedly causing the enlargement and infertility.

The timing of the varicocele is also debated. Some doctors claim that even though varicoceles may be detected in adolescence, the treatment can wait until the individual has any symptoms or is getting married. Others recommend varicocele repair in adolescence only if there is evidence of pain, testicular atrophy or if the sperm count is altered.

Observation for varicoceles

A varicocele is not of any great danger to health and one should not panic. For the young male in whom the varicocele is discovered incidentally, and there are no symptoms, the varicocele should be left alone.

For those males who are married and have a varicocele but are still able to have children, the varicocele should also be left alone.

For those who have mild pain or an ache and have no problems with sterility, supportive treatment with scrotal support should be tried first for at least 4-12 weeks.

Never go to a surgeon who recommends Varicocele repair without first giving you your options. In any case, in most cases where Varicoceles are treated, fertility is still not restored. If you have no pain and the varicocele does not bother you leave it alone.

What happens during testicular torsion?

When torsion occurs the testes rotates along the spermatic cord. During the rotation, it obstructs the blood flow. The stoppage in blood flow results in ischemia and no oxygen supply to the testes. The degree of damage to the testes depends on the duration of the torsion and the degree of twisting of the spermatic cord. Changes are evident in the testes soon after torsion and are reversible up to 4 hours. However, after 24 hours of torsion, the testes is almost always non functional and salvage is impossible.

Differential Diagnosis

Testicular torsion is a surgical emergency and if there is going to be any hope of salvage; it must be rapidly diagnosed and treated. Any delay in the diagnosis almost always leads to loss in the testes. Over diagnosis of the condition leads to unnecessary surgery. Data from hospital records indicate that testicular pain is quite frequent in teenagers and young adults. At least 20-40% of young males complain of some type of testicular pain at some point.

- Conditions which can mimic testicular torsion include
- trauma to the scrotum
- epididymitis (infection of the spermatic cord)
- orchitis (infection of the testis)
- incarcerated hernia
- varicocele
- idiopathic scrotal edema
- torsion of the appendix testis

Whenever there is trauma to the groin area, there is a general tendency to always attribute the scrotal pain entirely to trauma and become oblivious to the presence of testicular torsion. However, if the pain lasts more than one hour after the trauma, the testicle should always be evaluated for possible trauma-induced torsion.