Varicocele is a common cause of pain in the scrotum in men and often a cause of infertility or the inability to bear children in men. It is with these complaints the patient comes to a urologist.
But many times, the varicocele problem is detected incidentally through an ultrasound. Hence, a small percentage of cases who come to the Urologist show no symptoms.
What is Varicocele?
Varicocele means that the veins which are taking blood from the testes to the heart get abnormally dilated because they have some valves which get damaged.
Due to this, the blood starts to collect in these veins. When the blood starts to collect in these veins, these veins become dilated and the blood flow back from the testes to the heart is impaired.
Since the blood persists in these veins, the temperature of the testes increases. The testes have been placed outside the body so that their temperature can remain about two to four degrees lower than the core temperature of the body as this is the temperature that is required for the optimal production of the sperms.
But when the blood starts to collect in this area, then:
- it can cause pain
- it can cause a swelling around the scrotum, which is often visible if it is a high-grade varicocele
- it impairs the process of sperm formation
Most commonly what is found in these patients is that in the sperm parameters on semen analysis such as the motility of the sperms is impaired, which means that even though the sperms may be good in number, they are not able to move to the extent that they should be able to move to be able to fertilize the egg.
Symptoms of Varicocele
The most common symptom usually would be an impaired semen parameter which means that there will be some problem in the motility or the number or the shape of the sperms.
Also, there could be a pain in the scrotum which is usually a constant dragging pain. This pain increases or aggravates on standing for prolonged periods of time.
Usually when the patient gets up in the morning, there is no pain. Only when he is standing for prolonged periods, he would experience a discomfort or pain in the scrotum.
The third common symptom that the patient often notices is a swelling in the scrotum. He will find a wormy sort of a swelling, which means that he will feel that veins or the vascular structures around the testes appears to be dilated and enlarged.
The diagnosis is usually done through a clinical examination. When the patient comes to the doctor who checks the scrotum, he will find that there are dilated veins felt on examination of the scrotum.
This in medical science is called the ‘bag of worms’ feeling as if there are worms in a bag and you are kind of trying to feel them. To confirm the diagnosis a scrotal ultrasound is used. This is not a normal ultrasound, but a Doppler powered ultrasound.
Through a Doppler Ultrasound, the radiologist will be able to see the veins as engorged and there would be reversal of the flow of blood in these veins, which means that some blood will be going back from these veins into the testis.
So, based on the diameter of these veins, the radiologist will give a grade to the Varicocele which will also help the clinician to understand how severe the Varicocele is and how it should be best managed.
Varicocele Staging or Grades
With regards to the clinical staging of the Varicocele, there are three grades of Varicocele.
- Grade 1: The first grade is when the doctor can barely feel these veins. But when the patient is asked to cough or do a special manual called the Valsalva manoeuvre, at that time the doctor is able to feel those dilated veins.
- Garde 2: The second grade of Varicocele is when the doctor can feel them without this manoeuvre but are not able to see those veins as enlarged when looking at it from the outside.
- Grade 3: The third grade or the most severe grade of Varicocele is when the doctor can just look at the scrotum and say that you have Varicocele. So, there’s a visible enlargement of the veins and the veins look like a swelling on the upper part of the scrotum.
So, these are the three grades of Varicocele on clinical examination and there are four grades of Varicocele on ultrasound, which are based on the diameter of these veins.
Usually grade one and two Varicocele can be managed or controlled with medicines. The medicines in the form of tablets can increase the strength of the veins by depositing calcium in the wall of the veins.
Hence, they stop the further deterioration or damage to the veins and try and control the situation.
However, if it is the grade three, Varicocele, where a surgery is required wherein the veins must be ligated so that the blood does not flow in them any further.
It is also important to understand that many times if there is pain or discomfort in the testis despite the grade not being very high and all other causes have been ruled out, urologist consider surgical treatment for these patients as well because surgical treatment is more effective in pain management.
Surgery is also indicated when the size of the testicle is shrinking.
Surgical Treatment Options
Till few years back, a laparoscopic surgery was done and the root of the veins, from where the veins arise was ligated or tied which helped cure Varicocele.
But this laparoscopic surgery required the administration of general anaesthesia and was also an expensive surgery. Also, because of the other complications associated with this type of surgery such as hydrocele, recurrence and damage to the testis, the laparoscopic surgery became less in vogue.
The other treatment options used to be an inguinal approach to tying the veins in which a large cut was made just like for a hernia operation and the veins were exposed and individually tied.
And since this required a large scar of about three to four inches and because several complications were associated with this process, it became less common.
The two processes which are followed today for the surgical treatment of Varicocele are:
- Embolization – In this process, through a large vein of the groin region called the femoral vein, a wire is inserted until the veins of the testis.
And then an angiography sort of a process is done in which the veins are visualized, and a coil is placed in the veins. Hence, it is a major vascular procedure. But the advantages are that it is a short procedure and usually the patient can be discharged on the same day as the surgery.
This is one key reason why many patients like to go for the vascular embolization of the Varicocele. The problems with this option are that the coil can sometimes migrate and because we are invading the main blood vessels, it is a riskier procedure.
It is also a relatively newer procedure and hence not as time trusted as a conventional surgery. The complications associated are similar to Sub inguinal Microscopic Surgical Repair of the Varicocele, but coil migration and vascular complications are peculiar and dangerous. Cost wise also this process is more expensive.
- Sub inguinal Microscopic Surgical Repair – This process is now accepted as the gold standard or the preferred way to manage Varicocele.
In this process, a small cut of about 7-8mm is made at the root of the scrotum. Through this cut all the veins are exposed. Each vein is individually identified and tied and cut, and the artery is preserved. This entire process is done under a microscope with high magnification of about 20 times.
The advantage of using a microscope is that the damage to other structures such as the lymphatics, the artery and the tube that carries the sperm called the ‘Vas’ is very less. Hence, it is the simplest way of treating a Varicocele with least chances of recurrence and any associated complications.
This procedure lasts for about an hour and it can be done under regional or local anaesthesia. The patient can be discharged the same day. The cost too is almost half of what a patient would spend in the Embolization procedure.
The recovery period after any sort of procedure is about a week because there may be some swelling around the area and the tied veins still have accumulated clotted blood in them.
The veins slowly shrink in size and the swelling recedes and disappears completely in about 4-6 weeks. However, the patient can resume his normal work in a couple of days after the procedure.
Hence, Varicocele management is simple in today’s time. If it’s a high-grade Varicocele, the suggested treatment is a sub-inguinal microscopic surgical repair. And if it is a low-grade Varicocele, the patient can be treated through medication.
For more details on Varicocele surgery and management, you can contact our experts from the Urology center at the CK Birla Hospital. Book an appointment on +91 124 4882200 to evaluate and provide customized treatment options based on your condition.