Varicocele: what it is, causes, symptoms and treatments

• When we talk about varicocele we refer to the accumulation of blood in the veins present in the pampiniform plexus that feed the testicles. 
• There can be many causes of varicocele formation, usually associated with other pathologies that can lead to the appearance of vascular nodules.
• Testicular varicocele can be repaired by different surgical interventions, although the most common and advisable is inguinal varicocele surgery.

A varicocele is the dilation of the veins that drain blood from the testicles. In most cases, this anomaly of the testicular veins occurs unilaterally, that is, affecting only one testicle. However, although the chances are very small, bilateral varicocele can also occur, affecting both the left and right testicle.

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You should know that the symptoms of this pathology are generally not serious, although they can cause pain or be a cause of infertility. Therefore, treatment will help to solve the symptoms and reduce their effects on your fertility.

Varicocele is a progressive pathology, so the expansive process of varicose veins or vascular nodules can be classified into various levels of severity. To better understand the complexity of the types of varicocele, the Dubin international classification is taken into account, which determines the degree of varicocele taking into account parameters such as palpation of the presence of varicocele or its size.

• Grade 0 or Subclinical: this is a varicocele that is neither palpable nor visible at rest or by means of the Valsalva manoeuvre (which consists of increasing abdominal pressure by performing actions such as coughing, increasing venous pressure). It can therefore only be diagnosed by means of an imaging test, i.e. a Doppler or testicular ultrasound.
• Grade 1: this type of varicocele can be diagnosed only by palpation of the testicles when performing the Valsalva manoeuvres, as mentioned above, in order to raise the venous pressure and encourage the appearance of vascular nodules.
• Grade 2: when this degree of varicocele is reached, your specialist is able to palpate the presence of varicose veins of the pampiniform plexus without the need to perform the Valsalva manoeuvre.
• Grade 3: when you have a varicocele of this grade, the pathology can be seen with the naked eye without the need for palpation or other diagnostic tests.

In addition to this classification, in order to better understand how this pathology can affect you, we will now explain three more types of varicocele and how they differ. To do so, we refer to the Nistal-Regadera studies, which classify varicocele as follows:

• Diffuse spermatic varicocele: this type of varicocele is caused by the formation of varicose veins or accumulation of venous blood in the anterior part of the pampiniform plexus. In this case, the entire anterior pampiniform plexus is affected and completely surrounds the testicle.
• Focal spermatic varicocele: unlike the previous typology, in this case the involvement is found only in some portions of the anterior pampiniform plexus, so that there are dilated veins and veins that are not dilated.
• Cremasteric varicocele: this is the grade of varicocele in which the lesion occurs in the posterior pampiniform plexus so that only the tail and the posterior part of the testicle are affected.
• Mixed varicocele: this is the grade of varicocele in which there are lesions of the previous types, the anterior plexus and the posterior pampiniform plexus. It usually appears in advanced stages of varicocele and corresponds to grade 3 according to Dubin's classification.

Many agents may be involved in the development of varicocele, which is why it is considered a multifactorial pathology. Even so, the most common causes are:

• Greater pressure on the left side of the scrotum: The vascularisation in the testicular area is exerting greater pressure on the left side, as the testicular vein has a greater route to flow into the left renal vein, while the right vein flows into the inferior vena cava, much closer and with a significantly lower pressure.
• Age: During puberty there is a considerable increase in blood flow, which can lead to dilation of the veins in the testicles, resulting in varicocele. This pathology usually occurs in young men between the ages of 15 and 25.
• Hereditary factor: When there are cases of this disease in the family, any man is likely to develop it during his lifetime.
• Prolonged standing: As with varicose veins in the legs, prolonged standing causes the blood vessels in the testicles to overexert themselves to counteract the force of gravity and thus maintain proper circulation.

Although the symptoms of varicocele are ambiguous and difficult to associate exclusively with this pathology, normally the most common symptoms and those that most patients, and probably you, present are:

• Swelling of the scrotum: Due to the dilation of the testicular veins, the scrotum is usually more swollen than normal, which can cause discomfort when moving and limit your daily life.
• Testicular pain: As a consequence of the previous symptom, the inflammation in the area and the blood pressure can cause pain when urinating, in the buttocks area or the presence of blood when urinating or in the sperm.
• Decreased sperm count: Dilation of the veins in the spermatic cord causes the temperature to rise in this area, decreasing sperm production and quality.
• Enlarged and twisted veins in the scrotum: It is possible that as the pathology progresses, the veins increase in size due to dilation and accumulation of blood in them. Also, due to lack of space, the veins begin to twist and cause discomfort.

Although varicocele most often occurs only on the left side, you can also suffer from bilateral varicocele, which should be treated immediately because the chances of infertility and other serious complications are more likely to occur when both testicles are affected.

The appearance of this testicular condition, in most cases, is caused by the appearance of a retro peritoneal tumour or cirrhosis of the liver that compresses the venous plexus responsible for nourishing the testicle. To check whether the appearance of venous nodules is the result of other health problems, your specialist will carry out various tests to complete the diagnosis.

On the other hand, it is usually a hereditary problem that can cause long-term dilation of the venous plexus, accumulate blood and, consequently, seriously alter testicular flow. You should bear in mind that this is a pathology that almost never presents symptoms and is detected in routine examinations performed by the urologist when the reasons for fertility problems are unknown.

To solve the problems caused by varicocele, specialists resort to different treatments, the definitive remedy being surgery. The surgery is adapted to the degree of the pathology and the particularities of the patient.

There are basically four types of varicocele surgery: subinguinal varicocelectomy with 4x magnification; Palomo retroperitoneal surgery; laparoscopic varicocelectomy; and the most common, inguinal varicocele surgery.

To determine that surgical treatment is really necessary, the specialist will take into account the following factors:

• Testicular pain caused by the varicocele.
• A grade 3 varicocele, even if it is painless.
• The testicle that does not have a varicocele is smaller than normal.
• Bilateral varicocele.
• In the case of early sterility during adolescence, caused by the varicocele.

You should know that if you have any of the above conditions, surgery is highly recommended and is your only option for repairing the problem. Below, we explain in more detail what the surgical procedure consists of.

Although, as we have mentioned above, there are different types of surgical interventions to repair the problem, the most common is inguinal varicocele surgery. In order for you to better understand what this surgical process consists of, if you continue reading you will find the steps that you would follow until the operation is completed.

Varicocelectomy surgery preoperative

Before the operation it is always necessary to carry out a preoperative examination, which will help to prevent risks during the procedure, to know for sure the type of anaesthesia you will be given and to determine whether you are fit for the surgical intervention or not. 

The following tests will be necessary for this:

• Electrocardiogram: This test allows the surgeon and anaesthetist to know your cardiovascular health.
• Blood test: The purpose of this test is to determine that you do not have any abnormalities or pathologies, such as infections, which can delay surgery until it is under control.
• Chest x-ray: This is a test that is only performed if the doctor determines it necessary, to ensure that you do not have an infection and that your trachea is correctly aligned, in case you require intubation.

Inguinal varicocelectomy: step by step

On the day of the operation, you should arrive at the hospital a couple of hours before the surgery. Before you enter the operating theatre, you will be taken to a room where you will be asked to change into scrubs. 

You will also usually be given antibiotics to prevent infection during and after the varicocelectomy. 

You will then be taken to the operating theatre where the surgery will begin:

• First of all, in the operating theatre, you will meet the surgeon, together with the anaesthetist and the nursing team. The anaesthesia will be administered and once you are under its effects, the surgery will begin.
• Then, if necessary, the inguinal area where the incision to access the inguinal canal will be made will be shaved.
• The surgeon will make an incision of about 5 centimetres and then remove the spermatic cord with a special surgical instrument, open it and ligate the internal veins that cause part of the problem, preserving the artery, the lymphatic vessels and the vas deferens. The external spermatic veins are then ligated.
• Finally, the surgeon reintroduces the venous plexus into the inguinal canal, sutures and repairs the incision site and completes the varicocelectomy.

The duration of varicocelectomy surgery is approximately 20 to 60 minutes.

However, for each patient, the length of the surgery will depend on whether it is a unilateral or bilateral varicocele.

After waking up, you will be taken to an intensive care unit where you will remain until you are fully recovered from the anaesthesia and your vital signs are normal.

Although this is an outpatient operation, it is advisable to stay in hospital for at least 1 day after surgery to rest properly and to ensure that everything has gone well.

If we have helped you learn more about varicocele surgery and you are interested in going ahead with the procedure, please feel free to request a consultation with one of our specialists by clicking on the image below:

Do you need varicocele surgery?

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