Varicocele is a common urological disease in young men. It is not malignant, does not turn into cancer, and is not life-threatening. If left untreated, it will cause infertility and sexual dysfunction in the future. There is no treatment with medication or herbal methods. The most effective method in the treatment of the disease is varicocele surgery performed by microsurgical method. There is much controversy regarding the treatment of varicocele. Most of these discussions are about whether the disease should be treated and who should be treated. In this article, I will give information about in which cases varicocele should be treated, in the light of current literature and taking into account my own experiences.

What is varicocele: general information

Varicocele is a varicose vein of the testicle that is often seen in the left testicle. It is seen in approximately 15% of men. Approximately 40% of patients who apply to infertility clinics due to infertility have varicocele as the cause. It is a disease that can be treated with surgery, and a success rate of 70-80% is achieved after surgery performed with the microsurgery method.

Complaints in patients increase depending on the degree of varicocele detected during the examination (gradation indicating the size of the enlarged veins). In Grade 1 varicocele, varicoceles are detected during examination when the patient takes a deep breath and inflates his abdomen, in Grade 2 varicocele, varicoceles are palpable during manual examination without the patient straining, and in Grade 3 varicocele, there is a visible varicocele.

Varicocele generally occurs during the investigation of couples due to infertility, and sometimes patients consult a physician with complaints such as swelling in their testicles and pain when standing for a long time. These complaints are mostly seen in patients with high-grade varicocele.

It has been known for a long time that varicocele can cause infertility, but in recent years it has been shown that this disease can cause some complaints in men other than infertility.

What is the most effective method for treating varicocele?

Drug therapy or herbal treatments have no place in the treatment of varicocele disease. There are different treatment methods. We can list them as follows:

• Classical surgical method
• Microsurgery technique
• Laparoscopic method
• Embolization treatment

Among these treatment options, the most effective method and now considered the gold standard treatment is microsurgery. If the disease is present on both sides, surgery is performed in the same session (bilateral microsurgical varicocelectomy). Varicocele surgery is no longer performed using the laparoscopic method. Because recurrence is common after surgeries performed with this method. With embolization therapy, embolization (closure) of dilated veins is performed. Special chemicals prepared for this purpose are used here.

This method is a very old technique. It was first implemented in the 1970s. It is more developed today. In recent years, the embolization method has also been used in the treatment of varicocele, but its long-term results are not as known and effective as microsurgery. Improvement in sperm parameters and childbearing rates are higher after microsurgery. For these reasons, microsurgical varicocelectomy is considered a gold standard treatment method in the treatment of varicocele. We have been performing surgery on our patients with this technique for nearly 25 years.

What are the factors affecting success after varicocele surgery?

In order to achieve greater success in the surgical treatment of this disease, patients need to pay attention to some issues. Points to consider in order to increase fertility, that is, the chance of having children, after varicocele surgery:

• If there is a female factor, it should be evaluated by a specialist gynecologist.
• If there is an alcohol and smoking habit, it should be stopped.
• Patients who are overweight must definitely reach their ideal weight.
• If necessary, patients are started on supportive treatments to regulate sperm production.

In which cases should surgery be performed for varicocele?

Not every varicocele requires surgery. If the varicocele is at a low stage, there is no complaint of infertility, and there is no testicular atrophy, these patients do not need treatment. In the following cases, varicocele surgery must be performed:

• If there is grade 2.3 varicocele in adolescence
• If you have infertility
• If there is pain due to varicocele
• If there is bilateral and significant varicocele
• If there is testicular atrophy (testicular shrinkage)
• If testosterone hormone is low (hypogonadism)
• If there is a decrease in sexual desire (decreased libido, loss of libido)
• If there is erectile dysfunction

What are the problems that varicocele may cause if left untreated?

If varicocele is left untreated, it causes serious sexual problems (sexual dysfunction) along with infertility. We can list them as follows:

• Infertility: Varilocele has an important place in male infertility. It is a cause of infertility that can be treated with surgery. The success rate is higher if surgery is performed in the early stages, before serious damage occurs to the testicles.
• Premature ejaculation: Another negative effect of varicocele is that it causes premature ejaculation. This side effect has been revealed in scientific studies. Varicocele is considered to be a secondary cause of premature ejaculation.
• Erectile dysfunction: Hypogonadism resulting from varicocele, that is, the decrease in testosterone production, causes erectile dysfunction (impotence, erectile dysfunction).
• Hypogonadism (Testosterone deficiency): The testicles have two important functions: One of them is to produce sperm cells, and the other is to produce the male hormone called Testosterone. In varicose testicles, both sperm production and testosterone production are reduced. This type of testosterone deficiency is called “hypogonadism.” As a result, some sexual problems occur in men. Especially testicular atrophy and the resulting hypogonadism are more common in Grade 2 and Grade 3 varicoceles.
• Atrophy of the testicles (reduction in testicular size): Testicular sizes decrease in testicles with varicocele compared to the other. Since sperm development is not complete in childhood varicoceles, a spermogram is not required. If the child has varicocele (especially Grade 2 and Grade 3), these cases must be operated on. In childhood varicoceles, small testicle size is a reason for surgery. During this period, if there is testicular atrophy due to varicocele, the testicle that shrinks with surgery returns to normal. In this regard, testicular examination in boys should not be neglected. On the other hand, if adult testicles have shrunk due to varicocele, this testicular size will not return to normal with treatment, but surgery must be performed to prevent testicular damage in the future. There is no need for spermiogram analysis in children who will undergo varicocele surgery, as in adults.
• Pain: Male patients, especially those who work in jobs that require standing for long periods of time, experience pain in the groin. Since dull pains that are not very serious will disturb the patients, surgery should be performed in those with such complaints. Varicocele-related pain is more common in patients with Grade 2 and Grade 3 varicocele. In patients, pain typically decreases while lying down. Not every varicocele patient experiences pain in the groin. If the pain is due to varicocele, it will be resolved with surgery, but pain not related to varicocele continues in the postoperative period. Patients should be informed about this before surgery.

Are additional treatments required for patients who have varicocele surgery?

Whether additional treatment will be given to patients who have undergone surgery due to varicocele depends on the patient’s condition. The urologist starts sperm production regulating drugs and supportive treatments according to the patient’s pre-operative sperm and hormone tests. If hormone levels (testosterone) are low, these patients may also require hormone therapy. Apart from these, if there are alcohol and smoking habits that negatively affect sperm production, they must be stopped. The doctor may refer suitable patients to assisted reproductive techniques by consulting with an experienced gynecologist. In patients who have a low chance of getting results from medical treatment, assisted reproductive techniques should be used without wasting too much time and thus couples should be able to have children.

In summary: To summarize, varicocele is not only a disease that must be treated in men who cannot have children, but also patients with Grade 2 and Grade 3 varicocele must be treated even if they have children, as it can cause premature ejaculation, erectile dysfunction, hypogonadism, testicular atrophy and pain. . In untreated cases, there is no life-threatening situation, but some sexual problems may occur.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY