Testicular varicocele

• Testicular varicocele is one of the leading causes of male infertility in the world and has a higher incidence than is known.
• The diagnosis of testicular varicocele is usually made by chance during an examination for infertility, although there are cases where it is visible to the naked eye.
• Testicular varicocele can be treated with a variety of surgeries, but all have a fairly comfortable and straightforward recovery.

Testicular varicocele is the accumulation of blood in a group of blood vessels called the pampiniform plexus within the spermatic cord of the human testicles. This accumulation of venous blood, which we call testicular varicocele, causes an increase in the size of the veins and favours the formation of sinuous tracts, which we call testicular venous tortuosity.

The importance and severity of testicular varicocele in men is directly related to infertility, as numerous studies around the world show that 70% of male infertility is determined by the presence of testicular varicocele.

It has also been determined that 15-20% of the adolescent and young adult population may have some degree of testicular varicocele. Similarly, among men suffering from testicular varicocele, it is estimated that approximately 40% of them will experience male infertility.

The causes or origin of testicular varicocele formation are defined in two types of causes, primary cause and secondary cause.

• The primary cause of testicular varicocele formation is unclear and multifactorial, although it has been observed that it is possible that some people are genetically prone to suffer from it, as the incidence of testicular varicocele is higher among siblings and children of patients who have suffered or are suffering from it.
• Secondary causes of testicular varicocele are varied but better defined than in primary testicular varicocele. These causes are renal cell carcinoma, peritoneal tumour, peritoneal fibrosis and liver cirrhosis with portal hypertension.

The types of testicular varicocele are usually classified according to the DUBIN classification, determined by the size of the venous accumulation in the pampiniform network and its clinical manifestations. The different degrees of testicular varicocele according to their severity are:

• Grade 1. Testicular varicocele that can only be explored by performing Valsalva manoeuvres.
• Grade 2. Testicular varicocele that is palpable at rest by manual urological examination.
• Grade 3. Testicular varicocele that is visible without the need for testicular exploration.

The symptoms of a testicular varicocele are often ambiguous and unclear, as in 80% of cases there are usually no direct signs or symptoms of disease. Men suffering from testicular varicocele are usually diagnosed during routine examination by a urologist or primary care physician during a male infertility work-up for reproductive difficulties.

On fewer occasions the patient may consult for pain or a feeling of heaviness in the groin area and on far fewer occasions, the size is so large that patients consult specialists because of the enlargement.

For the diagnosis of testicular varicocele, as we have explained above, the main thing in the diagnosis of this pathology is the suspicion that there is a problem. 

In a patient who is unsuccessfully seeking conception with his partner, manual examination of the scrotal sac of the testicles and the testicles themselves is a fundamental part of the process. In this examination, a decrease in the size of the affected testicle in relation to the testicle on the other side can be detected. 

Small fibrous and tortuous tracts can also be palpated in the testicle affected by varicocele.

The suspected diagnosis of testicular varicocele by manual examination by the urologist or primary care physician should be followed by testicular ultrasound. Of the two most important types of testicular ultrasound for the detection of a testicular varicocele, colour Doppler ultrasound is the one with the highest diagnostic sensitivity (very close to 100% sensitivity and specificity).

On the other hand, in the case of normal testicular ultrasound without Doppler, the decrease in size of a testicle below 2 cm (testicular hypoplasia), the presence of tortuous varicose veins within the spermatic cord and a diameter of the largest vein greater than 3 mm during the valsalva manoeuvre are sufficient to diagnose a testicular varicocele. 

Testicular ultrasound has a sensitivity of 98% and a specificity of 99%.

A spermiogram is not a definitive way of diagnosing testicular varicocele, as alterations in the number or volume of spermatozoa are only indicative of infertility, which does not necessarily have to be caused directly by a testicular varicocele. 

Nevertheless, in patients with reasonable diagnostic doubts and suspected examinations, it is a further argument in favour of the presence of a varicocele. The most common spermiogram findings are usually oligospermia, asthenospermia and teratospermia.

Sperm venography and the use of radioisotopes and computed tomography (CT), which used to be used for the diagnosis of testicular varicocele, have been discarded in recent studies due to their high invasiveness and the standardisation of tests that are harmless to humans, such as the new ultrasound scanners.

The definitive treatment for testicular varicocele remains surgical intervention. There are several types of surgical techniques to successfully treat a testicular varicocele, and the use of one or the other depends on the type of patient.

The indications for testicular varicocele surgery are clear. A man should undergo surgery to repair a testicular varicocele as long as the following characteristics are met: testicular pain caused by the varicocele, when a grade 3 varicocele is present even if it is not painful, when the testicle on the side of the varicocele is smaller than normal (if we remember the above mentioned, it is defined as less than 2 cm in diameter), when it is bilateral or when the varicocele is in an adolescent with alterations in his spermiogram.

When the patient fulfils at least one of the above indications, he/she should undergo surgery for the repair and removal of a testicular varicocele. Overall, there are three main surgical methods for the operation of varicocele: open surgery, laparoscopic surgery and radiological intervention.

Radiological interventionism for the repair of testicular varicocele consists of embolisation or tamponade of the dilated spermatic veins by means of a type of catheterisation usually performed by interventional radiologists. This option is currently usually used in patients who have already undergone more than one unsuccessful surgical intervention and who have suffered a recurrence of the disease. In this case, sperm venography would be necessary.

For the other two testicular varicocele repair options we have a large conglomerate of interventions, the most important of which are laparoscopic varicocelectomy, subinguinal varicocelectomy with 4x magnification glasses, open groyne surgery and Palomo retroperitoneal surgery.

All these options have been performed in recent years with different characteristics. Palomo retroperitoneal surgery has the highest recurrence rate (recurrence of testicular varicocele) compared to the others.

Open groyne surgery and laparoscopic varicocelectomy are similar options and certainly the most commonly chosen by surgeons today. Both have very similar recurrence rates although the laparoscopic option tends to be more difficult to perform and in some cases appears to have a lower success rate when measured against the possibility of reproduction after the operation.

Open groyne surgery and microsurgery are usually the therapeutic options of first choice for testicular varicocele repair.

The main postoperative complications of testicular varicocele repair are those related to the immediate postoperative period, such as pain, the possibility of infection and recurrence or new formation of the varicocele. 

On the other hand, it is very rare that the atrophy suffered by the testicle does not recover, being more than 90% of cases of this improvement. Although it is possible, chronic testicular pain after surgery is very rare.

Open groyne surgery for the repair or resolution of a testicular varicocele usually takes between 30 and 60 minutes. It is usually possible for the patient to return home the same day after a few hours in the post-operative recovery room. However, if the operation has taken longer or the patient's co-morbidity is complex, the patient may need to stay overnight to better control postoperative pain and ensure anaesthetic aftercare.

In approximately 2 weeks, the patient can return to normal activities. Depending on the patient's work, this return to daily activities may be sooner or later.

The stitches are usually removed after around 10 days, although it will depend on the patient's age and whether or not the wound has become infected for this period to be shorter or longer. 

Wound care is basic and the patient can do it perfectly well at home. It should be noted that the wound should be treated at least every 12 hours and that the wound area should always remain very dry.

If the cause or the problem for which the patient visited the specialist or his family doctor was the infertility study, a spermiogram should be carried out at least 4 weeks after the intervention in order to objectify the possible changes for the better after the intervention.