Varicocele Treatment

Many varicoceles cause no symptoms, and tend to be found during a fertility examination. When the symptoms do show up, they tend to begin with a dull, dragging, aching or heavy feeling on the left side of the scrotum. This can progress to discomfort after long periods of standing, exercising, heavy lifting or later in the day, which eases upon lying down.

 

After a point, an enlarged twisted clump of veins resembling a ‘bag of worms’ might be visible or palpable above the testicle. The left scrotum could also seem visibly lower hanging. Non-symptomatic findings mostly revolve around the impact of fertility. Over time, the affected testicle itself could usually grow smaller than the other one.

 

This progression tends to take years, in most cases, and is often noticed only during the symptomatic stage. Ideally, it should be addressed before the testicle starts shrinking and semen measures and quality gets affected, leading to potential infertility.

 

Causes of Varicocele

A varicocele, as explained above, follows the same principle as a varicose vein in the leg. When blood doesn’t drain efficiently from the veins around the scrotum.

 

These veins have one-way valves that keep the blood moving upwards towards the heart. If the valves are weakened or do not close properly, the blood tends to ‘backflow’ and collect in the scrotal veins. Over time, these veins stretch and enlarge much like varicose veins in the leg. Varicocele veins aren’t particularly fragile, but since they sit around the sensitive testicle, even a mild enlargement can cause heaviness or aching. So, a varicocele tends to become noticeable sooner than a varicose vein in the leg.

 

Varicoceles are more common on the left side because the left testicular vein takes a longer, less direct route through the abdomen and joins a larger vein at an angle that increases pressure. Typically, they first become noticeable during puberty, when blood flow to the testicles starts increasing.

 

In most people there is no single prevalent cause. Family history can play a role to some extent. Very rarely, a new varicocele may show up — especially on the right side, or in an older man — as the result of blockage of blood flow higher in the abdomen due to a kidney mass. A sudden manifestation of this nature prompts an immediate medical evaluation.

Treatment is not needed for every varicocele. It is only considered if the varicocele becomes a meaningful health concern. It’s quite common for the scrotal vein to be enlarged, without causing any fertility issues.

 

Only when fertility gets affected, there is ongoing pain or reduced testicular growth in teenagers is an intervention considered. Treatment itself aims to block blood flow in the enlarged vein. It doesn’t necessarily guarantee pain relief or fertility, so the approach is largely tailored to an individual’s goals.

The first step, in general, is an examination by a urologist/andrologist. This examination is conducted while standing, often with a Valsalva maneuver — the patient is asked to take abreath, close their mouth, pinch their nose, and gently breathe out or strain without letting air pass out. Much like the effort used when passing stools. This temporarily increases the pressure inside the chest and abdomen.

 

Doing this while standing makes blood pool more visibly in the enlarged scrotal vein, thereby making it easier for the doctor to feel. It also becomes slightly easier to see a small varicocele which may otherwise be less obvious.

 

After this, the anatomy is confirmed with a colour Doppler ultrasound, if necessary. To understand the impact on fertility, the key baseline tests are two semen analyses. Additionally, doctors may recommend testing of the patient’s partner (if there is one), and some consideration of hormones and genetic testing when sperm abnormalities are severe.

 

Upon understanding the medical significance of the varicocele and importantly, its effects on the quality of life, a line of treatment is discussed. The first line is treatment with medicines. Unfortunately, medicines cannot shrink or repair the enlarged veins, however, they can manage some symptoms. Pain relief meds can ease aching. Supportive underwear or scrotal support can reduce the pulling/heavy sensation during work. Avoiding prolonged standing or heavy lifting is also recommended. If the symptoms still don’t reduce, then further treatment options are considered:

 

Varicocele Embolization

This is a minimally invasive procedure for treating a varicocele. It is usually preferred if a varicocele returns following surgery. Microsurgery tends to be favoured where fertility is the core focus, but embolization is more dependent on the anatomy and availability of experienced interventional radiologists.

 

The radiologist inserts a thin tube (catheter) through the groin or neck, under local anesthesia. Using fluoroscopy for guidance, and contrast dye, the doctor reaches the abnormal testicular vein and blocks it with tiny coils, plugs, or a sealing medicine. Blood is then redirected to healthier veins. Most people return home on the same day.

 

Microsurgical Subinguinal Varicolectomy

This is, as the name implies, a microscopic surgery. The surgeon makes a small cut just below the groin, near the base of the penis, rather than entering the abdomen. Using an operating microscope, they identify and seal the enlarged veins that allow blood to pool around the testicle. The microscope is crucial to the procedure because it helps preserve the vas deferens, lymphatic vessels and the testicular artery. Preserving these structures reduces the risk of a hydrocele (fluid collection around the testicle), recurrence, or damage to blood supply.

 

The process is usually performed on general anesthesia, especially if the patient prefers to remain asleep through the procedure. Spinal (spine-downwards) or regional anesthesia may also be used, especially in centers accustomed to day-care urology. The choice depends on patient comfort and anxiety, comorbidities (heart, lung, spine, clotting and other medication related factors) and surgeon experience.

 

One of the major advances is the use of an intra-operative micro Doppler to confirm arterial blood flow before and after the veins are treated. This particular procedure is associated with low recurrence and complication rates compared to non-surgical methods.

 

Laparoscopic Repair

This is considered when both sides are affected or when another abdominal procedure is planned alongside. It’s a keyhole operation performed under general anesthesia. The surgeon makes two to three small incisions in the abdomen, which is then gently inflated with carbon dioxide gas, to create more ‘working space’. A tiny camera and fine instruments are inserted through the incisions. Viewing the veins on a monitor, the surgeon clips or seals the enlarged vein, so blood is rerouted through other healthy veins.

 

Compared to a microsurgery, this procedure involves minor risks of bleeding, hydroceles, injury to nearby structures and recurrence. The small wounds heal quickly, and in many centers, patients are discharged on the same day or after a short overnight stay.

The complications tend to vary, based on the procedure. Varicocele surgery or embolization is usually very safe, but there are some implications.

 

Temporary bruising, swelling and tenderness around the incision areas is common. Sometimes, a small collection of blood can pool under the skin, around the incision or scrotum. Infection and bleeding are rare, but require immediate addressing if they occur.

 

Procedure-specific risks include recurrence of the varicocele, no reduction in pain or symptoms, and a hydrocele (a collection of fluid around the testicle). Very rarely, a testicular artery may be injured during a procedure, which affects blood flow to the testicle. Microsurgery aims to mitigate this risk by clearly identifying the artery and lymphatic vessels. However, the risk can’t entirely be counted out.

 

Embolization has different risks — exposure to contrast dye, which is nephrotoxic (bad for kidney function) and X rays. Occasionally, the catheter doesn’t reach the target vein or the blocking material gets dislodged from the intended position. Generally speaking, varicocele treatments are in a low-risk category, but it’s still necessary for patients to be sufficiently oriented before consenting to a procedure.