Varicocele and its symptoms

• Varicocele usually does not present symptoms to the naked eye, but in cases where it does, it must be diagnosed during a medical consultation.
• Symptoms of varicocele range from a decrease in the size of the testicle to a genetic alteration of the sperm.
• Most of the symptoms of varicocele imply the need for surgical treatment to avoid further complications.

A varicocele is a collection of venous blood in a group of small veins called the pampiniform plexus in one of the male testicles. 

Surprisingly, it is estimated that 90% of the time it usually occurs in the left testicle, 7% may be bilateral and in the remaining 3% it is predominantly found in the right testicle. In the vast majority of cases, varicocele surgery will be necessary to resolve the symptoms.

Symptoms of testicular varicocele are rare. In most cases the presence of a varicocele in the testicle is not detected until a physical examination by the urologist or family doctor. 

The presence of a varicocele is usually detected when the male patient comes to the clinic for pain, a feeling of heaviness in the groin area of the pelvis or during the couple's infertility study.

During this interview, the family doctor or urologist may discover the presence of dilated and tortuous veins during the examination or detect a decrease in the size of the affected testicle compared to the other testicle. 

At this point, if the diagnosis is not clear or if he/she is looking to determine more precisely what degree of varicocele the patient has, he/she may ask for the complementary examination of reference for the study of varicocele, which is the testicular Doppler ultrasound.

Having outlined the above, we can conclude that the diagnosis of varicocele is often ambiguous and sometimes difficult, as the symptoms of varicocele can cover a wide range of possibilities and symptoms. 

The main symptoms of varicocele are explained below:

Pain and heaviness as symptoms of varicocele

On certain occasions the presence of pain in the area adjacent to the testicle or scrotal sac together with discomfort or a sensation of heaviness on one or both sides of the groyne area may be the first symptom of varicocele. 

Many other differential diagnoses are possible with this symptom, as the general sensation of heaviness means that the attending physician must think about and rule out a large number of pathologies. 

The presence of discomfort when urinating or the sensation of not having emptied the bladder after each urination could be more indicative of a urinary tract infection.

On the other hand, pain radiating to the buttocks with blood in the urine or sperm could point to a prostate infection. An enlargement of one testicle in relation to the contralateral testicle could indicate, in addition to a varicocele, the presence of a hydrocele or a testicular tumour.

Therefore, pain or heaviness in the testicular or groyne area is usually the main symptom of varicocele for which patients usually consult a specialist or family doctor. However, the final diagnosis can be complicated, especially in the early stages of varicocele.

Infertility as a symptom of varicocele

Infertility as a symptom of varicocele is usually not very prevalent in our environment, but this does not mean that there is no direct relationship.

It is estimated that 40% of men with infertility present or manifest symptoms of varicocele, although only approximately 16% of men with a varicocele are infertile. 

It has not been possible to detect a direct relationship with absolute certainty, although it is believed that the presence of varicocele symptoms increases the temperature of the affected testicle, thereby decreasing the production of sperm for reproduction and directly altering the functionality of the testicle through a decrease in blood supply.

Infertility is defined as the failure to reproduce by a couple who have been trying for one year to conceive a child without using contraception. 

The presence of infertility in a couple, which until recently was almost exclusively attributed to the woman, has been divided in responsibility with the man as scientific evidence has studied male sexuality. 

It is now estimated that 50% of cases of infertility in a couple are partly or wholly attributed to the man.

There are many causes of male infertility. One of the main causes of male infertility that can be repaired is varicocele, which presents the symptoms explained above and in the following points. Other causes of infertility in men are due to medication, such as the use of drugs that alter in one way or another the production and quality of spermatozoa in the sperm fluid, drugs such as allopurinol, valproic acid, cyclosporine, calcium antagonists, etc.

Another of the main causes that can be surgically repaired are cryptorchidism or alterations in the situation and location of one or both testicles so that they are not able to descend into the scrotal sac, which can cause testicular dysfunction and, consequently, an alteration in the formation of sperm and spermatozoa. This type of alteration can be congenital or acquired.

Another reason for male infertility is often obstruction of the ducts that carry sperm fluid. Male infertility may also be due to hormonal factors related to testosterone secretion by the testes or a hormonal disturbance at the level of the brain altering testosterone precursors in the pituitary-pituitary-hypothalamus-testes axis. 

Immunological and/or genetic alterations also affect male infertility, although less frequently, and it is estimated that 6% of infertility may be due to this type of alteration.

Retrograde ejaculation, which is nothing more than the exit of seminal fluid through the bladder instead of the urethra during a man's orgasm, is another of the causes that can lead to infertility in couples. In this case, the nerves that coordinate the opening of the urethra with the outflow of seminal fluid through the seminal vesicles are affected.

Testicular atrophy as a symptom of varicocele

Testicular atrophy as a symptom of varicocele is not very common and usually occurs in advanced stages of the disease, i.e. when the varicocele is so large that blood flow to the affected testicle is reduced.

When blood flow to the testicles is reduced, there are two mechanisms by which testicular atrophy occurs to a greater extent. One of these is a decrease in the arrival of hormonal substances secreted by the hypothalamus (a hormonal organ located in the brain), which under normal conditions stimulate the production of testosterone in the testicles.

With the arrival of fewer of these substances, there is a decrease in testosterone production, which leads to a decrease in testicular size and atrophy of the testicle. The other mechanism is produced directly by a decrease in the blood flow that irrigates and nourishes the testicle, so that if the blood supply of nutrients and oxygen is reduced, the testicle responds by decreasing in size.

Testicular enlargement as a symptom of varicocele

The paradoxical enlargement of the testicle as a symptom of varicocele occurs not as a true enlargement of the testicle, which as mentioned above actually atrophies and decreases in size, but as the patient's sensation that one of the testicles is enlarged.

This sensation is caused by increased venous retention in the pampiniform plexus that forms the varicocele, increasing in size and causing, as a characteristic symptom of varicocele, an increase in the size of the scrotal sac, which can sometimes be seen directly without the need for physical examination by the urologist or family doctor. 

This grade of varicocele is classified as grade 3 and is a symptom of varicocelewith a direct indication for surgical intervention for its complete resolution.

Genetic alteration as a symptom of varicocele

The genetic alteration as a symptom of varicocele is produced and explained as a result of the testicular atrophy explained above. By reducing blood flow to the testicle and interfering with the hypophysis-hypothalamus-testicle axis, testicular atrophy can occur, which, depending on the degree of varicocele and the degree to which the atrophy is affected, can cause the spermatozoa that mature in the testicle to be altered and grow and mature as abnormal forms of spermatocytes.

This genetic alteration as a symptom of varicocele is not very frequent and corresponds to advanced stages of varicocele and testicular atrophy, generally leading to infertility and not to alterations in a future foetus.

The only definitive way to solve the symptoms associated with testicular varicocele is surgery. To find out more about this procedure, click on the following image: