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 some individual studies have demonstrated that sperm improves after varicelectomy.⁴ Other studies showed that the adverse influence of the varicocele increased 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. Recent reviews do not support varicocele repair to improve fertility.¹⁰

• 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 (between 2 and 10% have symptoms) and only rarely cause pain.
• The scrotum is often described as feeling 'like a bag of worms'.
• 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:
  • The scrotum on the side of the varicocele hangs lower than on the normal side.
  • Dilation and tortuosity of the veins increases with standing and usually decreases on lying down. The varicocele cannot usually be palpated lying down.
  • Performing the Valsalva manoeuvre whilst standing increases the dilation.
  • There may be a cough impulse.
• 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.
• However examination is not the most accurate method of detection and where detection is important (particularly in infertility) other methods of investigation are required.¹³

The diagnosis is not usually difficult. However beware of secondary varicocele. Rarely varicocele can be secondary to other pathological processes blocking the testicular vein.¹⁴ For example, tumours of the kidney and other retroperitoneal tumours may involve the renal vein and obstruction of the left testicular vein.^15,16 If on the right consider situs inversus.^17,18

• 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.¹⁹ 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.²⁰ 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 possibly (controversy surrounds this recommendation)
• To prevent testicular atrophy

Approaches to surgery include:

• Inguinal
• Retroperitoneal
• Infrainguinal or subinguinal

All methods involve ligation of veins to prevent abnormal blood flow. 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.

It was common practice to recommend referral for repair of varicoceles if:

• Varicocele palpable
• The couple had documented infertility
• Female partner had normal fertility or correctable infertility
• The male partner had one or more abnormal semen parameters or sperm function test results

However doubt has been cast on the merits of repair following a review of the evidence.¹⁰

• Refer urgently to a urologist to exclude a tumour:
  • If a varicocele appears suddenly, especially if the man is older than 40 years of age and the varicocele remains tense when lying down.
  • If there is a solitary right-sided varicocele.
• Refer to a urologist if there is uncertainty about the nature of a scrotal swelling.
• Refer routinely to a urologist for consideration of varicocele ablation:
  • If it is causing distress or embarrassment.
  • If there is pain or discomfort.
• Refer adolescents with a varicocele to a urologist:
  • If there are concerns about reduced ipsilateral testicular volume.
  • If the boy or parents/guardians are concerned and cannot be fully reassured in primary care.
• Do not routinely refer men with a left-sided varicocele for ultrasonography to look for an underlying tumour.
• If a varicocele is found in the male partner of an infertile couple consult the CKS topic on Infertility²² for more information on assessment and when to refer. The National Institute for Health and Clinical Excellence recommends that men should not be offered surgery for varicoceles as a form of fertility treatment because it does not improve pregnancy rates.²³

Some old studies suggested conception rates improved in about half of patients after surgery, with one study for example showing a doubling of pregnancy rate.²⁴ A Cochrane review in 2006 was inconclusive.²⁵ However recent evidence does not support repair of varicoceles for infertility and NICE have taken note of this.¹⁰ Some have also questioned the need for surgery with the advent of intracytoplasmic sperm injection techniques (ICSI). There would be cost advantages and safety advantages (avoids risks to female partner of IVF) if evidence supported varicocele repair as a means of improving fertility.

There is no evidence that early operation in adolescents gives better andrological results. Referral is recommended as above.