Varicocele

Synonyms: Acute Varicocele = Lover's Nut.

A varicocele is an abnormal dilatation of the testicular veins in the pampiniform venous plexus caused by venous reflux. They are important because they are a well- recognised cause of reduced testicular function and are associated with male infertility. This link with infertility was first proposed by Barfield, a British surgeon, in the late 19th century.

Varicoceles are more common on the left for anatomical reasons:

• The angle at which left testicular vein enters left renal vein
• Lack of effective valves between testicular and renal veins
• Increased reflux from compression of renal vein (between superior mesenteric artery and aorta). This is sometimes called the Nutcracker Syndrome or Aorto-Left Renal Vein Entrapment Syndrome.^1,2

There is a detrimental effect on sperm quality. In about 20% of adolescents with varicocele fertility problems will arise.³ However the reasons for this are less clear.Theories abound:

• Pressure effect
• Oxygen deprivation
• Heat effect- perhaps the most popular theory
• Accumulation of toxins

Whatever the reasons it has been demonstrated that sperm improves after varicelectomy.⁴ The adverse influence of the varicocele may increase with time.⁵ However some question this hypothesis.⁶There is a suggestion that repair before age 14 may give better results in terms of testicular function, although testes remain smaller.^7,8,9 However there is no evidence that treatment of varicocele at younger age will give better andrological results.

• It is unusual in boys under age 10 years
• Incidence increases after puberty
• The incidence of 15-20% in adolescents is similar to that in adults
• They are found in 40% of infertile males

History

• Usually asymptomatic and only rarely cause pain
• Patients may report scrotal heaviness
• May be an incidental finding, being discovered at routine medical examinations or noticed, in children by parents
• Infertility investigations.The high prevalence of varicoceles in subfertile males emphasises that they are the most important cause of poor sperm production and reduced semen quality.

Examination

• Careful examination, with the patient standing, is the most important method of detection. However it is not the most accurate and where detection is important (particularly in infertility) other methods of investigation are required.¹⁰
• The scrotum is often described as feeling 'like a bag of worms'
• Most are in the left testicle (80-90%), some bilateral (as many as 35-40% radiologically¹¹) and very few just on the right side
• Size. They vary in size and may be classified as:
  • Large. Easily identified by inspection alone. Sometimes called Grade III.¹²
  • Moderate. Identified by palpation, but without performing the Valsalva maneuver. Grade II.
  • Small. Identified only by 'bearing down' to increase intra-abdominal pressure (impedes varicocele drainage) and increase size of varicocele. Grade I.

The diagnosis is not usually difficult. However beware of secondary varicocele. Rarely varicocele can be secondary to other pathological processes blocking the testicular vein.¹³ For example, tumours of the kidney and other retroperitoneal tumours may involve the renal vein and obstruction of the left testicular vein.^14,15 If on the right consider situs inversus.^16,17

• Sperm counts may be done as part of fertility investigations but are difficult and often inappropriate in adolescents.
• Doppler studies. This is the method of choice to diagnose varicocele but is not indicated unless physical examination is inconclusive.¹⁸ These should be high resolution to demonstrate venous reflux into the pampiniform plexus. Studies are performed in the supine and upright positions. If demonstrated on ultrasound only it is described as subclinical. Other imaging methods used to evaluate varicoceles include:
  • Venography
  • Radionucleotide angiography
  • Thermography
  • CT scans may be required to identify tumours obstructing the testicular vein
• Colour-flow Doppler ultrasonography. This defines both anatomical and physiological aspects of varicoceles by combining real-time ultrasonography with pulsed Doppler in the same scan. Colour demonstrates direction of blood flow, including reverse flow in the varicocele.
• Ultrasound examination.¹⁹ This can assess testicular volume. If one testis is 2 mL smaller than the other it is hypoplastic.
• Serum follicle-stimulating hormone (FSH), luteinising hormone (LH) levels and response to luteinising hormone-releasing hormone (LHRH). Testicular injury can be assessed by a supranormal LH and FSH response to LHRH.

Some controversy and difficulties of interpretation arise from the size definition of the dilated veins. Some take 3mm as the threshold diameter and others (usually surgeons) take 2-3mm (3 or more veins, resting diameter).

• There are no effective medical treatments
• Surgical repair of subclinical varicoceles is not usually recommended, although opinions differ
• Not all varicoceles require surgery. Surgery has the potential to cause testicular damage.

However the primary treatment of varicoceles is surgery, and indications include:

• Pain
• Infertility:if
  • Varicocele palpable
  • The couple has documented infertility
  • Female partner has normal fertility or correctable infertility
  • The male partner has one or more abnormal semen parameters or sperm function test results
• To prevent testicular atrophy

Approaches to surgery include:

• Inguinal
• Retroperitoneal
• Infrainguinal or subinguinal

All methods involve ligation of veins to prevent abnormal bloodflow. The recurrence rate is usually less than 10%.
Other less commonly used methods include the percutaneous transvenous approach and laparoscopic routes. Generally speaking these have higher risks and no better benefits. Angiographic occlusion techniques are less invasive but have a higher failure rate.

3-4 months after surgery improved semen parameters can be detected. Ultimately conception rates are improved in about half of patients after surgery, with one study showing a doubling of pregnancy rate.²⁰ Some question the need for surgery with the advent of intracytoplasmic sperm injection techniques (ICSI). However there are cost advantages and safety advantages (avoids risks to female partner of IVF) to varicocele repair. In azoospermic or severely oligospermic men it may avoid the need for invasive sperm retrieval procedures for subsequent IVF-ICSI. Such patients rarely achieve spontaneous pregnancy after varicocele repair alone.

There is no evidence that early operation in adolescents gives better andrological results, but the recommendations are that repair should be undertaken in children and adolescents:

• Varicocele is associated with abnormally small testes
• There is another testicular condition affecting fertility
• Bilateral palpable varicoceles
• Abnormal sperm quality in older adolescents
• Supranormal LHRH stimulation test results
• Symptomatic varicocele (as in adults) which may include psychological discomfort

Repair of other varicoceles should only be undertaken after follow-up and when reliable sperm analysis can be performed.