Varicocele is one of the important diseases that cause infertility in men. The most important feature of this disease is that it can be treated with surgery. Testicular damage due to varicocele is related to the stage and duration of the disease. The earlier the patients apply to the physician and the surgery is performed, the higher the success rate. In this article, I will give general, up-to-date information about varicocele, taking into account my own experiences.

What is varicocele?

Varicocele is the enlargement of the veins of the testis (spermatic vein, pampiniform plexus) similar to that in the legs, that is, its varicose. It is often seen on the left side. It can be seen in 90% left testis, 8-10% in both testicles. In varicocele, sperm count decreases, sperm quality decreases and as a result infertility (infertility) occurs. It is frequently seen in young people, but it can also be seen in children, although it is rare (1%). It is seen in 15% of boys aged 13-15 years.

In cases of varicocele seen under the age of 17-18, there is no need to have a spermogram because the sperm production is not fully mature, the examination is sufficient for the decision of surgery. If there is shrinkage in the testis after childhood operations, the testis will return to its normal size over time, but shrinkage in adult testicles does not become normal after surgery.

What are the causes (etiology) of varicocele?

The cause of this disease is not fully known. Some theories have been proposed for the cause of varicocele. It is possible to summarize them as follows;

• The exact cause of varicocele is not known exactly.
• Mostly seen in puberty (adolescence)
• Insufficiency of the valves in the veins (veins)
• It is often seen on the left side (for anatomical reasons)

What are the risk factors for varicocele?

There are no known very specific risk factors for the development of varicocele. Some known risk factors are:

• It may be a risk factor, as it is common in those who stand for long periods of time.
• It can be seen frequently in those with varicose veins in the lower extremities (legs).
• It may be genetic (hereditary). It is 3-8 times more common in first-degree relatives with varicocele.

What can happen in the future if varicocele is not treated?

Varicocele disease does not pose a vital problem, but if left untreated, it can lead to serious problems in the future. The following problems may occur in the future due to untreated varicocele:

• Testicular atrophy: Testicular shrinkage occurs with the effect of increased pressure and toxins in the veins, especially in high-grade varicoceles for a long time. This can cause sexual problems (impotence, erectile dysfunction) in men along with infertility in the future.
• Infertility: With the effect of increased heat and toxins, sperm production, sperm motility and functions are impaired and infertility occurs. Microsurgical surgery improves infertility at a high rate.
• Sexual dysfunction (Erectile Dysfunction, Erectile Dysfunction): Especially after a long time, if testicular atrophy (shrinkage) due to varicocele and hormonal disorders have developed, sexual dysfunction may be observed.
• Premature ejaculation (premature ejaculation): It has been reported in some studies that varicocele causes premature ejaculation.

What are the symptoms (patient’s complaints)?

Varicocele rarely causes symptoms. Patients mostly go to the urology doctor because of the inability to have children after marriage, and the disease is detected during this time. Sometimes, they apply to the doctor with the complaint of palpable and visible vascular enlargement in the bag (scrotum) or pain, especially when standing for a long time. The most common symptoms in varicocele;

• Pain: There are rarely or no symptoms in varicocele. Very rarely, pain may occur, especially as a result of standing for a long time. This pain is usually not very severe, but in the form of a blunt pain. The pain can sometimes be severe, usually in the form of a feeling of fullness. Increases with prolonged standing or physical activity, relieves in lying position
• Infertility: Fertility is adversely affected in varicocele, that is, infertility occurs. Since these patients are usually young men, they mostly apply to the doctor after marriage because they do not have children.
• Swelling in the scrotum: It is a progressive disease, varicose veins enlarge and become evident over time. The veins become prominent and envelop the testis like a warm pack, mostly on the left side.

When should patients with varicocele consult a doctor?

Since varicocele does not cause serious symptoms, these patients usually apply to the doctor because of infertility after marriage, rarely because of pain and swelling in the testis. If these patients have the following complaints, they should definitely consult a urologist;

• Pain: If patients have groin pain that does not go away, especially while standing.
• Swelling: If swelling has occurred in the veins in the scrotum (bag)
• Infertility: If they could not have a child despite having unprotected intercourse for one year.

Varicocele examination

Varicocele examination should be done standing, in cases with varicocele, enlarged veins are seen especially on the left. In small varicocele cases, enlarged varicose veins are detected by closing the mouth and nose of the patient and increasing the intra-abdominal pressure (Valsalva maneuver). If not detected in physical examination, these veins can be shown with Doppler ultrasonography.

What are the varicocele grades (Grade, stage) on examination?

Grade is done to show the degree of varicocele disease, that is, the enlargement of the data. This rating is determined by the outcome of the outpatient examination. Varicocele is divided into 3 grades (stage, grade) according to the examination result.

• Grade-1: Varicocele cases detected during palpation as a result of the patient closing his mouth and nose in the standing position and pushing.
• Grade-2: It is the condition of mild varicocele in standing examination, which becomes evident with straining.
• Grade-3: It is varicocele that can be seen without any straining in an outpatient examination and becomes more evident as a result of straining.

Classification of varicocele by ultrasonography

Scrotal color Doppler ultrasonography (USG) is a frequently used diagnostic method in the evaluation of patients with varicocele. With scrotal color Doppler USG, varicocele is divided into two groups:

• Stop type varicocele: If there is no back leakage (reflux) in the testicular veins on USG when the patient breathes deeply and inflates his abdomen, it is called a stop type varicocele. This type of varicocele is also known as subclinical varicocele.
• Shunt type varicocele: When the patient increases the intra-abdominal pressure in the supine position, there is a backward flow (reflux) in the testicular veins on USG.

How is varicocele diagnosed?

It is very easy to diagnose varicocele. Varicocele is easily diagnosed with the examination of the patient. In some cases, there is not enough vascular enlargement to be palpable in the examination, in such cases varicocele is diagnosed by scrotal ultrasonography. There is no need for further radiological examinations.

Sometimes there may be cases of varicocele that cannot be detected on examination, but can be demonstrated by scrotal color Doppler ultrasonography (USG). This is called a “subclinical varicocele”.

In which cases varicocele surgery is required?

Not every varicocele patient needs surgery, varicocele surgery is required if:

• If there is pain (especially in those who stand for a long time, there is pain in the groin)
• If there is testicular atrophy (reduction in testicular size) and softening
• If there is infertility, surgery is absolutely necessary in these cases.
• If there is deterioration in the sperm analysis (spermogram)
• If the vein diameter is 3 mm or more in ultrasonography
• If there is significant varicocele on examination (Grade 2 and 3)

What patients should do before going to the urologist

Before going to the doctor, the patients should prepare the questions they are curious about and ask the doctor, and give appropriate answers to the questions that the doctor may ask in the diagnosis. Patients may ask the doctor questions such as:

• What could be the reasons for my complaints?
• Which tests do I need to have?
• Is this condition temporary or permanent?
• Will this affect my ability to have children?
• What types of treatment options are available, which is the most suitable for me?
• What are the options suitable for my health condition?
• Are there any restrictions in terms of sex?
• Is there any written documentation or a resource you can suggest?

The doctor may also have some questions to ask the patient

The urology doctor may ask questions similar to the following in order to assist in the diagnosis of his patients who apply for varicocele;

• When did the complaints start?
• Are complaints permanent or temporary?
• Are the complaints serious or mild?
• What do you do to reduce your pain?
• Are there any dums that make your complaints worse?
• What tests are available? (spermogram, hormones, testosterone, prolactin, FSH, LH; scrotal color Doppler USG).

How is the pre-operative preparation?

There are some issues that should be done before varicocele surgery and that patients should pay attention to. These;

• Routine tests required for anesthesia before surgery are taken
• If blood thinners are used before the operation, they are discontinued 5-7 days before the operation.
• Patients who used drugs due to their chronic disease should use these drugs regularly, and consultation from the relevant specialist should be requested if necessary.
• Patients stop eating and drinking orally 4-5 hours before the operation.
• Hospitalization is done 1-2 hours before the operation.
• Patients read and sign consent forms required for surgery.

What kind of anesthesia is given in varicocele surgery?

If the patient is weak, surgery can be performed even under local anesthesia. But we usually prefer spinal anesthesia (numbing from the waist down) or short-term general anesthesia. can be given.

How long does varicocele surgery take, how many days does he stay in the hospital?

The duration of the operation depends on whether the disease is unilateral or bilateral, and the number of vessels. It usually takes about 30-45 minutes on average. The patients are discharged the same day after the effect of the postoperative anesthesia wears off and their general condition improves. Sometimes you may be kept in the hospital overnight.

What are the treatment-surgical methods in varicocele?

The definitive and most effective treatment of varicocele is surgery, that is, surgery. Not all patients need surgery, most people with varicocele can have children without any treatment. Single and young men who want to have children in the future should have surgery, especially if they have Grade 2 and 3 varicoceles. High-grade patients who do not undergo surgery are more likely to have testicular damage and future infertility.

Surgical methods used in the treatment of varicocele are as follows;

• Open surgery-microsurgery: These are the methods performed without using microscopic surgery or a normal microscope. Here, the enlarged veins of the testis are ligated by separating them from other structures under the microscope by entering through an incision of approximately 2 cm from the inguinal region. The best treatment today is microsurgery. Here, even very small veins are ligated using a microscope. In addition, lymph vessels and testicular artery (arterial) are seen under the microscope and it is ensured that they are not connected. In this method, testicular atrophy and hydrocele formation, recurrence (repeat) are extremely rare. Microsurgery is the treatment method accepted as the gold standard in the treatment of varicocele and with the best results. In the literature, there are many scientific studies showing that the complications and recurrence rates of the operations performed with this method are lower and the rate of having children is much higher than other methods. We have been performing our surgeries with this method for many years.
• Lapatroscopic – robotic varicocele surgery: Varicocele surgeries performed with laparoscopic and robotic methods are not widely used methods.
• Percutaneous embolization: It is based on the treatment of varicose veins with sclerosing agents (vascular occlusive). This method has now been abandoned because of the high recurrence rate.

What are the advantages of microsurgery in the treatment of varicocele?

Today, microsurgery is accepted as a “gold standard” method in the treatment of varicocele. The advantages of varicocele surgery with microsurgery are as follows;

• The recurrence rate is extremely low
• Hydrocele formation is very low
• Development of testicular atrophy is extremely rare.
• Improvement rate in sperm parameters is high
• The rate of having children is high

Complications that may occur as a result of varicocele surgery

Varicocele surgery is not a very heavy operation, but it is a microsurgical operation with special features. Complications are almost non-existent in careful and experienced hands. As with any surgery, some complications (complications) may occur depending on varicocele surgery. We can list these complications as follows:

• Hydrocele (fluid collection in the membranes surrounding the testis)
• Recurrence (recurrence of varicocele)
• Infection
• Damage to testicular arteries (arteries) resulting in testicular atrophy (shrinking).

What should be considered after the operation?

Patients return to their normal daily lives 1 week after the operation. It would be appropriate not to work hard for 3-4 weeks, to wear comfortable clothes, not to lift heavy, not to do heavy sports.

How long does it take to recover spermogram values ​​after varicocele surgery?

It is necessary to have a spermogram at the earliest 3 months after the operation. The best improvement occurs at 6 months, 9-12. better results in months. In general, an average of 60-75% improvement in spermogram occurs after varicocele surgeries. If the patients still cannot have children even though their spouse is normal and there is no improvement in spermogram values, additional treatments should be started or they should be referred to IVF centers without losing much time, especially if the woman’s age is advanced.

Is there a herbal treatment for varicocele?

There is no alternative medicine or herbal treatment in the treatment of varicocele, the gold standard treatment is microsurgery. However, with the recommendation of a urologist, appropriate supportive treatments and a healthy diet can improve sperm values.

Recommendations for patients after varicocele surgery

The success rate after varicocele surgery with microsurgical method is very high. If patients pay attention to the following points after surgery, the rate of improvement in spermogram and conception is higher;

• Cutting down on alcohol and cigarettes
• Overweight patients reach their ideal weight.
• Doing regular sports
• Healthy and balanced diets
• To use additional supportive treatments (if necessary) given by the doctor

In conclusion: Varicocele is a largely curable disease if treated timely and appropriately. Today, the “gold standard” treatment method of varicocele is microsurgical surgery. With microsurgical treatment, patients can have children, and possible negative effects in the future are prevented.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY