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Brian A. Roelof, M.D. A varicocele is a cluster of dilated veins that are usually associated with the left testicle. These dilated veins are similar to varicose veins that are commonly seen in legs. Ordinarily blood flows into the testicle through the testicular artery and returns to the heart by way of the testicular veins. These veins should have "check valves" in them so that, when the patient is standing, the blood does not flow backwards down the vein towards the testicle. If the check valves do not work properly, the veins will become engorged and swell because of the backward flow of blood when the patient is standing. This is the same mechanism as varicose veins of the legs. Varicoceles can decrease fertility, cause a smaller testicle, and occasionally can cause aching. Varicoceles are very common. They may be found in 15-20% of men on routine physical examination. Varicoceles are often found in adolescents on sports physical examination or when men are being evaluated for fertility. The mechanism by which varicoceles affect fertility is not known for certain. The leading theory is that the warm blood flowing backwards from the body keeps the testicles too warm and thus reduces the ability of the testicle to produce adequate quality and number of sperm. There are other theories, such as the backwards flow of waste products coming from the kidney and adrenal gland that could affect the ability of the testicle to produce good sperm. In adult infertility clinics, it is known that many of the men have a varicocele and have poor sperm counts and poor sperm quality. Often the sperm count and quality improve if the varicocele is surgically corrected. It is also known that most men with a varicocele do not have any difficulties with fertility and are able to have all of the children that they wish to have. The problem with the adolescent male with a varicocele is in trying to determine which ones might have future fertility problems and which will have normal fertility. A varicocele can induce significant changes in the testicle which can lead to a progressive deterioration of the function of the testicles. Until ten years ago, very few pediatric urologists treated teenagers with a varicocele. If a teenager was discovered to have a varicocele he was merely alerted to the possibility of a problem in the future. Since then more pediatric urologists have been selectively performing a prophylactic varicocele repair to prevent future fertility. If one waits until an adult male with a varicocele has documented infertility and then treats the varicocele, the return of fertility is possible in approximately 50% of those individuals. Thus, early treatment may be beneficial in certain individuals, but it is probably not necessary in others. We are still unable to specifically predict which males with a varicocele will have a low fertility. In males over the age of 17, semen parameters should approximate standard adult norms (a semen specimen is analyzed under the microscope for the number of sperm and quality of sperm). If there is poor quality and or low numbers of sperm, a varicocele repair would probably be offered. In teenagers under 17, we are much more limited in our evaluation. The general consensus is that, if there is a significant difference in the size of the left testicle compared to the right, (testicular growth retardation) then a surgical treatment is warranted. Some would also add that, if there is a very large varicocele rather than a small or moderate varicocele, a surgical correction would also be considered. If a varicocele is present and the testicular size is the same on each side, we believe that the individual should be followed with once a year examinations, perhaps until their family is complete. A varicocele operation is usually done under a general anesthetic in a hospital operating room. A small incision is made in the left lower abdomen (like a hernia incision), a muscle layer is opened. The dilated veins are identified and divided and ligated. This is done as an outpatient surgery. A local anesthetic is often placed in the wound before the patient wakes up so that there is minimal pain for the first few hours. The patient will have some restrictions on their activity for the first couple of weeks while they are healing. An alternative is a laparoscopic ligation of the veins. This is performed by passing a small tube with a telescope through the area of the belly-button and a couple of other small incisions are made so that working instruments can be passed into the abdomen. The vein is found as it is running through the abdomen back towards the heart. This procedure has the advantage that the healing time is faster and there is less postoperative pain. The disadvantage is that it is changing an operation that is technically outside of the abdomen for an operation that technically goes through the abdomen and, thus, there is a potential for bowel injury and other abdominal organ injury. This is also a considerably more expensive procedure. It has not been performed for enough years to know if it has results that are as good, better, or worse than the standard procedures. |
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