Varicocele

What is Varicocele ?

Varicocele refers to the abnormal dilatation of the veins which carry blood from the Testis to the heart. These veins have valves which are responsible for the smooth flow of blood from the testis to the heart. The testis are placed naturally out of the body so that their temperature is two degrees lower than the rest of the body. This is to allow optimal sperm production as the process of spermatogenesis works better at lower temperatures. As the valves gets damaged, more and more blood starts to collect in the veins and increases the temperature around the testis.

How does Varicocele Impact Health ?

Due to an increase in the temperature the testicular sperm production becomes suboptimal and the sperms produced may be poor in quality with defects in structure and motility. Increased collection of blood also has been found to generate more free radicals that damage the normal sperm. Apart from the damage caused to sperms varicocele can also lead to pain in the testis due to local damage resulting from the distended veins. The problems arising due to varicocele can be summarized as follows:

  • Derangement in semen parameters and infertility
  • Reduction in the size of the testis
  • Pain and heaviness in the testis

This leads to the following symptoms:

  • Pain in the lower part of the tummy and the scrotum
  • Decrease in the size of the testis
  • Inability to conceive or father a child

There are some patients who have varicocele but do not have any of the above symptoms. These patients usually have very minor varicoceles and do not need any treatment for varicocele. However most patients with a clinically significant varicocele have symptoms. Presence of these symptoms are an indication for treatment of varicocele.

Varicocele is identified as a dilated bunch of veins which can be felt or seen above the testis. This is possible by a thorough examination by an experienced andrologist.

If the varicocele is very mild, it may not be possible to diagnose it on clinical examination and a doppler scan of the scrotum may be required. The treatment of varicocele varies on the grade of the varicocele.

How is Varicocele Diagnosed ?

There are some patients who have varicocele but do not have any of the above symptoms. These patients usually have very minor varicoceles and do not need any treatment for varicocele. However most patients with a clinically significant varicocele have symptoms. Presence of these symptoms are an indication for treatment of varicocele. Varicocele can diagnosed by clinical examination by an experienced andrologist. If in doubt the andrologist will confirm the diagnosis by getting the semen analysis and a doppler study of the scrotum. The semen analysis provides insight about the effect of the disease on sperms. The doppler ultrasound is crucial to identify the varicocele and also give an idea about the severeity of the disease.

How is Varicocele Treated ?

Treatment of varicocele depends on the grade or severity of the varicocele. The severity is best assessed by physical examination followed by doppler ultrasound of the scrotum.

  • For mild varicocele (Grade I), medications can be useful to alleviate the symptoms. Such mild varicoceles do not usually cause fertility issues.
  • For moderate to severe varicoceles (Grade II and Grade III) a surgery called Subinguinal Microscopic Varicocelectomy is performed.

What is Microsurgical Varicocelectomy

Subinguinal Microscopic Varicocelectomy surgery involves tying up the dilated veins and cutting them so that blood does not flow through them anymore. After the surgery flow across these dilated veins stops and the blood does not collect anymore. Once the temperature around the tesis reduces, the enzymes start to work once again and semen analysis returns to normal.Since there are many blood vessels present in the testicular cord, it is essential for good results that the surgery is performed under an operating microscope and that a doppler be used to identify the testicular artery so that it does not get ligated by mistake. If apart from the veins with defective valves, the artery or the lymphatics are injured during the procedure,  there are chances of the permanent loss of the testis or formation or a hydrocele (due to collection of lymph in the scrotal sac). The key to successful surgery is identification of all the veins and their ligation and sparing of the vas, testicular artery and the lymphatics to minimize complications. Varicocele surgery should be done by a urologist with interest in Andrology in a centre where facilities like operating microscope and microprobe Doppler is available. Centres where these surgeries are done on a regular basis have better results