Varicocele is a disease seen in approximately 20% of young men. If left untreated, it will result in infertility in the future. It is a surgically treatable disease. Today, the most effective treatment method in treatment is surgery performed with microsurgery technique.

In this article, I will try to give the frequently asked questions about varicocele and their answers in the light of my own experiences and current literature.

What is varicocele, on which side is it most common, what are the causes?

Varicocele is the enlargement of the veins of the testis, that is, its varicose veins. It is mostly seen on the left side. The exact cause of varicocele is unknown. Reasons such as the insufficiency of the valves in the veins are put forward.

Why is varicocele more common on the left?

Varicocele is mostly seen on the left side. The reasons for the higher incidence of varicocele in the left testis are anatomical reasons. The reasons why varicocele is seen more on the left are as follows:
• The veins of the left testis (with the vein) open into the left renal vein and this angle is in the form of a right angle. On the right, the right testicular vein opens into the vena cava (the main vein in the abdomen) with a narrower angle.
• The distance to the renal vein, where the left testis empties, is longer.

Will there be a bilateral varicocele or is the operation performed at the same time?

Varicocele is mostly seen on the left side. But sometimes it can be seen on both sides. If surgery is required, both sides are operated simultaneously in the same session.

Is varicocele a genetic disease?

Varicocele disease is genetically related to heredity. Close relatives or siblings are more likely to have the disease.

How is varicocele examination done?

Varicocele surgery is performed by opening a 2-3 cm incision from the groin. Enlarged veins are found and ligated and cut by finding the structure called the spermatic cord and containing testicular veins. During the operation, the semen duct (ductus deferens), testicular artery and facility lymphatics are preserved. We perform our surgeries with the microsurgery method.

What is the varicocele grade, how is it done?

Varicocele grade or grading is done by outpatient examination.
• Grade-1 (G-1) varicocele: While the patient is standing, he/she strains by covering his/her mouth and nose and testicular examination is performed. If the veins are palpable in this way, it is called a G-1 varicocele.
• Grade-2 (G-2) varicocele: If the veins are palpable without straining while the patient is standing, it means there is a G-2 varicocele.
• Grade-3 (G-3) varicocele: When the patient is examined outpatient, if there are visibly enlarged veins, it is called G-3 varicocele.

How is varicocele diagnosed?

It is very easy to diagnose varicocele. It is possible to diagnose by examining the patient. No further investigations are required. Scrotal ultrasonography (USC) is ordered to reveal the condition of the testicles and low-grade varicoceles (G-1). A spermiogram may be requested to evaluate sperm production. It is also useful to see the hormone values.

Will there be testicular and groin pain due to varicocele?

Varicocele patients may have pain in the testicles and groin and lower abdomen. However, these pains are not unbearable pains. It is especially seen in those who stand for long periods of time. These pains are sometimes confused with chronic prostatitis pain. If the pain is related to varicos, it can be corrected with surgery.

What does subclinical varicocele mean?

If the varicocele could not be detected in the outpatient examination and was detected in the color Doppler ultrasonography, this type of varicocele is called “subclinical varicocele”. These patients do not need surgery. If there is an infertility problem, surgery can be performed in this case, and according to some authors, it is controversial. If there is no other reason to explain infertility, there is no harm in performing surgery with microsurgery.

How is the spermiogram test in varicocele?

All sperm parameters are impaired in patients with varicocele. This is called the “stress pattern”. The number and movement of sperm decreases. Sperm have structural defects. Sperm’s ability to fertilize eggs is reduced.

What are the causes of varicosle-related infertility at the molecular level?

According to the current literature, the causes of varicosle-related infertility at the molecular level are:
a. DNA fragmentation in sperm
b. Sperm chromatin packaging
c. Disruption of mitochondrial membrane potentials and damage to mitochondria
d. Increased apoptosis in sperm

What happens if varicocele is not treated?

If varicocele is not treated, serious problems can occur. These:
• Infertility (infertility)
• premature ejaculation
• Impotence (erection problem, erectile dysfunction, ED, erectile dysfunction)
• Testicular atrophy (shrinkage of the testis)
• Hypogonadism (hormone deficiency, testosterone deficiency)
• Psychological problems
• Chronic inguinal pain, testicular pain

How is the preparation before varicocele surgery?

Routine blood tests, chest X-rays, bleeding and coagulation tests are taken from patients who will undergo surgery. Patients should not eat or drink anything 5-6 hours before the surgery.

How many hours does varicocele surgery take, how many days of hospitalization, what kind of anesthesia is given?

Varicocele surgery takes about 30-45 minutes on average. It is performed with spinal anesthesia (numbing from the waist down) or general anesthesia. Patients are discharged on the same day 5-6 hours after the operation. Sometimes it can be a one-day stay.

Which is the most effective and current treatment method in varicocele?

The effective treatment of varicocele is surgery. Today, the “gold standard”, that is, the best and most successful treatment method in the treatment of varicocele, is the surgery performed with the microsurgery method. We have been performing our surgeries with the microsurgery method for 20 years and our results are quite good.

Is varicocele surgery performed with robotic and laparoscopic methods?

The most effective and preferred surgical method in varicocele surgery is microsurgery. Varicocele is not made with the robotic method, the system is very expensive. Laparoscopic varicocele surgery was previously performed, but it has now been abandoned because of its high recurrence rate.

What should be considered after the surgery, when to do sports, how is the recovery process?

It is very comfortable after the surgery. Patients are discharged 5-6 hours after the operation and start to eat. The next day they begin their mild daily activities. After 4-6 weeks, they apor, they can lift weights. Since we cover the wounds aesthetically, there are no scars, they can go into the sea after a week.

What is the success rate in varicocele surgery?

Success after varicocele surgery is related to the patient’s condition. It has a 70-80% success rate. If there is no testicular atrophy before the surgery and the sperm values are not too bad, the success rate is quite high.

How long after the operation is a spermiogram required?

A new spermiogram test is requested at the earliest 3 months after varicocele surgery. It is compared with the previous values of the patient.

Is additional medication given after the surgery?

After varicocele surgery, additional supportive treatments can be given according to the patient’s condition. If the spermiogram is very bad and the hormone values are not normal, supportive treatments are started for these patients. For this purpose, vitamin supplements that stimulate sperm production and, if necessary, hormone drugs are given.

Is the use of antioxidant drugs correct in the treatment of varicocele?

Oxidative stress is increased in the testicles and seminal fluid in varicocele. As a result, sperm rich in free fatty acids are damaged. With varicocele surgery, it is aimed to improve sperm functions by reducing this increased oxidative stress. Oxidative stress is also important for sperm functions in small amounts, it is not correct to completely reset it. If it is reduced or reset too much, sperm functions will be damaged. This situation is called the “antioxidant paradox”. In this regard, varicocele patients must be followed and treated by a urology specialist.

What are the factors affecting the success rate after varicocele surgery?

Varicocele surgery does not give the same result in every patient. Factors affecting the success rate after varicocelectomy are:
§ Type of surgery: The success rate is higher with microsurgery.
§ Experience of the surgeon: The success of the surgeon with experience in andrology and microsurgery is higher.
§ Preoperative spermiogram: If the preoperative values are very low, the success rate is lower.
§ Testicular atrophy: If there is testicular atrophy before surgery, the success is lower
§ Age of the patient: The success rate is lower in patients over 40 years of age, better results are obtained at younger ages.
§ Patient’s lifestyle: The success rate is lower in people who use alcohol and cigarettes, have nutritional problems, have an irregular and sedentary life, have a stressful life, and are overweight (obese).

Does embolization have a place in the treatment of varicocele?

No. Embolization method has no place in the treatment of varicocele. This method was tried long ago (1980s), but it was abandoned because of the high recurrence rate. Today, the most effective treatment method in the treatment of varicocele is microsurgery.

In which cases varicocele should be operated, should every varicocele be operated?,

Not every varicocele needs to be treated. However, in some cases, it must be treated. The conditions that varicocele must be treated are as follows:
• Infertility (if any
• If there is severe pain
• If there is premature ejaculation, if varicocele is evident
• If you have an erection problem
• If there is Grade-2 and 3 varicocele
• In pediatric patients

Is varicocele seen in childhood, should it be treated?

Varicocele is seen before puberty. This is called “adolescent varicocele”. Varicocele is generally estimated to begin at the age of 9-12 years. If there is a childhood varicocele, surgery should be performed. Otherwise, testicular atrophy develops.

How is childhood varicocele evaluated?

In the pre-adolescent period, varicocele is usually detected during routine screening or when the family notices it. Sometimes the child notices the pain and swelling in the testicles himself. It is not correct to have a spermiogram test in patients with adolescent varicocele. Because sperm production is not fully developed during this period. Ultrasonography is sufficient only for examination and measurement of testicular dimensions.

Does varicocele recur after surgery?

After varicocelectomy (varicocele surgery), recurrence is seen at different rates depending on the surgeon’s experience. The method with the least or no recurrence is the microsurgical method. With this method, 1-2% recurrence can be seen.

If there is recurrent varicocele, how should it be treated?

If there is a recurrence of varicocele, if there is a recurrence after the operation, then the most effective treatment is to perform a re-operation with the microsurgery method. Methods such as laparoscopy and embolization have no place in the treatment of relapsed cases.

Is there a non-surgical treatment for varicocele?

No, there is no non-surgical treatment for varicocele disease. If there is varicocele, its treatment is necessarily microsurgery.

Does infertility occur in every varicocele patient?

No, infertility does not occur in every varicocele patient. This is related to the degree and duration of the varicocele, the patient’s age, lifestyle, and general health.

Does varicocele heal spontaneously, will it worsen over time if surgery is not performed?

Varicocele does not heal on its own. It progresses further over time. It progresses, especially in those who stand for a long time due to their profession. In this respect, it is not right to expect it to heal on its own.

Is it necessary for people who have children but have varicocele to have surgery?

This is one of the frequently asked questions by our patients. At the same time, this issue is frequently discussed among urologists. Varicocele surgery is not just for having children. Since varicocele will damage the testicles over time, sexual functions are also adversely affected. However, subclinical varicosles do not need to be treated. If the patient has a G-2,3 varicocele and the patient is young, surgery should be performed to prevent future testicular damage, even if they have children.

Are herbal treatments effective in varicocele?

There is no herbal treatment for varicocele. The only treatment method is surgery. In this way, we do not want our patients to waste time and money. If supportive treatment is required, it is appropriate to start this by a urologist after the surgery.

Is IVF treatment performed in patients with varicocele?

If a person has a varicocele and wants to have a child, varicocele surgery should be performed on this person before the in vitro fertilization method. Scientific studies have shown that more successful results are obtained with the in vitro fertilization method after surgery in varicocele patients. If the in vitro fertilization method is applied before varicocele surgery, the success rate is very low. We strongly recommend our patients with varicocele to undergo surgery before in vitro fertilization. Because with varicocele surgery, sperm functions improve and better results are obtained with in vitro fertilization.

Does varicocele patients have testicular atrophy?

Yes, test atrophy, that is, testicular shrinkage occurs in varicocele patients. This rate is higher especially in patients with long-term and G-2,3 varicocele. In this regard, we recommend our patients with G-2,3 varicocele to undergo surgery even if they have children.

Is testicular atrophy due to varicocele corrected with surgery?

Testicular atrophy, which develops due to every varicocele disease, does not improve with surgery. This is related to age. If varicocele-related atrophy has developed before the age of 18, this situation can be corrected with surgery. If varicocele has testicular atrophy and the patient has been operated after the age of 18, this atrophy does not improve. For this reason, we definitely recommend surgery when we see varicocele in our pediatric patients. According to our experience in pediatric patients, atrophic testicles recover after surgery and return to normal size.

Does varicocele cause premature ejaculation?

There are many reasons for premature ejaculation. It has been reported in scientific studies that varicocele can cause premature ejaculation. If a patient with premature ejaculation also has varicocele, we recommend surgery to these patients. In this way, we observed improvement in our compression patients.

Does varicocele cause erectile dysfunction?

The testicles have two important functions: producing sperm and making Testosterone. Over time, testicular atrophy develops due to varicocele and if there is testicular damage (atrophy), these patients may have erection problems. In addition, psychological reasons caused by infertility due to varicocele can also cause erectile dysfunction.

Is there azoospermia due to varicocele?

Yes, azoospermia due to varicocele (no sperm can be seen in the spermiogram) can be seen. This condition is more common in long-term and high-grade (G-2.3) patients.

Is azoospermia due to varicocele corrected with surgery?

This is related to damage to the testicles, the degree of varicocele, whether it is unilateral or bilateral, and whether there is atrophy in the testicles. If there is no testicular atrophy, the patients are not very advanced, and if azoospermia is due to varicos, there may be an improvement with surgery. If there is azoospermia due to reasons other than varicocele, azoospermia does not improve despite surgery.

Are there complications of varicose surgery, what are they?

If varicocele surgery is performed in careful and experienced hands, complications are extremely low and the success rate is very high. With microsurgery and careful surgeries, these complications are extremely few or not seen at all. There may be temporary complaints such as simple wound inflammation and discharge from the wound. The most important complications that can be seen due to varicocele surgery are:
§ Testicular atrophy: It is the shrinkage of the testis as a result of damage to the testicular artery during surgery.
§ Hydrocele: It is the accumulation of water around the testis as a result of damage to the lymphatics of the testis during surgery.
§ Injury of the semen duct: During the operation, the semen duct may be damaged, tied or injured.

Will those who have varicocele surgery have children?

Yes, it is possible to have a child after varicocele surgery. However, this situation is related to many factors such as the degree of damage to the testicles, the degree of deterioration in sperm parameters, and the age of the patient.

Is varicocele a dangerous disease?

Varicocele is not a dangerous disease. It does not turn into cancer. It does not adversely affect human health. It only causes problems such as infertility and erectile dysfunction.

What does shunt and spot type varicocele mean?

Shunt type and spot type varicocele is a type of ultrasonic classification. Accordingly, varicocele is divided into two groups:
• Stop type varicocele: If there is no backflow (reflux) in the testicular veins on ultrasound (USG) when the patient breathes deeply and inflates his abdomen, it is called a stop type varicocele. This condition is also known as subclinical varicocele.
• Shunt type varicocele: If there is a backward flow (reflux) in the testicular veins on USG, it is called a shunt type varicocele.

Are varicose veins seen in the legs of patients with varicocele?

Varicocele is a disease of the venous system. So it’s a venous disease. Patients with varicocele may also have varicose veins in the legs. Or people who have varicocele in their legs may also have varicocele disease. Since most varicocele patients are young patients, although varicose veins are not seen in the legs, it can be seen in advanced ages.

In which occupational group is varicocele common?

Varicocele disease can be seen in anyone. It is more common in those who stand for a long time due to their profession and they progress faster.

What should be considered if varicocele develops suddenly in advanced ages?

Varicocele disease is often seen in young people. It can occur suddenly on the right or left side in advanced ages. In this case, it is necessary to consider other diseases. A kidney tumor (cancer) may be considered if it occurs on the left. Kidney cancer compresses the renal vein, and varicocele may develop as the testicular vein opens into the renal vein on the left. Or it can be any disease that compresses the testicular veins in the retroperitoneal region. On the right side, since the testicular vein opens into the vena cava, tumors that compress the vena cava may develop a varicocele on the right.

Summary: Varicocele disease is a common disease. Varicocele is a non-vital disease. It is a condition that can lead to infertility and sexual problems if left untreated. The only effective treatment is microsurgical surgery (varicocelectomy). The surgery is a simple but delicate procedure. When performed in experienced hands, the complications are low and the success rate is high.

Many questions are asked by our patients about this disease and its treatment. In this article, I tried to answer frequently asked questions with up-to-date information.

Prof. Dr. Emin ÖZBEK, MD
Urology Specialist
Istanbul- TURKEY