Varicocele

What is a Varicocele?

A varicocele is a collection of swollen veins in the scrotum. It is a common condition, occurring in about 15% of young men, and usually causes only minor symptoms. In some men, however, a varicocele is associated with more severe pain which can be troublesome and interfere with normal activities.

Varicoceles can also be associated with reduced fertility and are therefore commoner in those men suffering from fertility problems. Varicoceles occur because of a problem with the valves in the veins which carry blood from the scrotum and testicles. The condition, therefore, shares some similarities with varicose veins in the legs, and pelvic congestion syndrome in females.

The Symptoms of Varicoceles

A varicocele often produces no signs or symptoms so it can be difficult to know if you have one. Sometimes, you may feel pain or discomfort. So, how do you know if you have a varicocele? Other symptoms include:

A Dull Ache in the Testicles
A Feeling of Heaviness in the Testicles
Visibly Swollen Veins
Visibly Smaller Testicle
Infertility

We are often asked, "what does a varicocele look like?" Over time, a varicocele grows and become more noticeable. Varicoceles usually have a 'twisted' appearance (see the above image) and have sometimes been described as looking like a ‘bag of worms’, and the condition might cause a swollen testicle - usually the left side.

Knowing when it’s time to see a doctor can be tricky, since you may not have any symptoms. As such, varicoceles often require no treatment, unless you are in pain or experiencing issues with fertility.

However, a swollen testicle is never a good sign, and you should speak with your doctor immediately if you have pain or notice a change in size to your scrotum.

What Can Cause a Varicocele?

Varicoceles occur because of a problem with the valves in the veins which carry blood from the scrotum and testicles.

A spermatic cord, within the pampiniform plexus, holds up each testicle, and this cord contains the veins, arteries, and nerves that support the testicles. In healthy veins, one-way valves move the blood from the testicles back to the heart.

When "leaky", these valves do not return the blood back to the heart as they should and this causes a buildup of pressure, and therefore swollen veins, and a varicocele develops slowly over time. They are more common on the left side of the scrotum as the left testicular vein is more prone to valve problems.

Despite this, there are no established risk factors for developing a varicocele, and the exact cause of varicoceles is still unclear. We know it is due to problems with the valves, but we aren't sure why they develop.

Why Do Varicoceles Appear on the Left Side?

Varicoceles are usually more common on the left side of the scrotum. This is because your body is organised in a way that means more blood flows on the lefthand side. Greater blood flow means more chance of a varicocele developing, which is why they are frequently diagnosed on the left side.

How Common are Varicoceles?

Varicoceles are pretty common, most estimates put the total number of men with varicocele at 15%. Despite this, they are not dangerous and mostly go unnoticed.

Do Varicoceles Go Away on Their Own?

Unfortunately, no. Once a varicocele is present it needs to have medical intervention to remove it. However, in many cases you can simply leave a varicocele if it is presenting no pain symptoms and is not a factor influencing your fertility.

What are the Risk Factors for Developing Varicoceles?

There don’t appear to be any significant risk factors for developing varicoceles, and the exact cause is still unclear.

Do Varicoceles Affect Testosterone?

A 2011 study did find that varicoceles can reduce testosterone production. The study looked at 325 men with a varicocele and compared their testosterone levels with 510 men who did not have a varicocele and found that, regardless of age, varicoceles have a statistically significant impact on testosterone levels. This study confirmed the findings of a 1992 World Health Organisation multicentre study that found varicocele presence correlates with lower testosterone in men over 30.

Varicoceles and Infertility

Despite the debate raging on, there is sufficient evidence to suggest that varicoceles can cause infertility, but only in a small number of men.

An estimated 10% to 20% of men diagnosed with a varicocele will experience problems fathering a child.

The exact cause of the infertility isn’t known, and in most cases where a man is infertile, he will also have a varicocele. This has led researchers to assume that varicoceles may impact sperm quality, which influences fertility. However, in most cases, varicoceles simply coexist with low semen parameters and have no direct impact.

How is a Varicocele Diagnosed?

You can check for a varicocele yourself by performing a physical examination, paying attention to swollen veins which have been described as feeling like a 'bag of worms'. If you feel something you think is abnormal, you can then make an appointment with your GP.

Diagnosing a varicocele is usually done via a physical examination by your GP or a specialist, such as an Interventional Radiologist or Urologist.

In some cases, your doctor may perform a scrotal ultrasound, which can help measure the spermatic veins and gives a more detailed, accurate, visual depiction of the condition.

The Grading System for Varicocele Size

Once diagnosed, your doctor will grade the varicocele with one of four grades:

Grade 0 - only seen by ultrasound. Sometimes referred to as a subclinical varicocele
Grade 1 - palpable only during Valsalva maneuver. This means that the doctor can feel your swollen veins but only when you take a deep breath and hold it while your doctor performs a physical examination.
Grade 2 - easily palpable but not visible. This means your doctor can easily feel the swollen veins, without a Valsalva maneuver, but cannot easily see them as there is no swelling or visible veins.
Grade 3 - easily visible. This means that your doctor can immediately identify a varicocele with just a visual examination

How to Manage and Treat Varicocele

Many men do not need treatment for their varicocele. Most men can take over-the-counter pain relief medication such as ibuprofen or paracetamol (always check with your GP if you are taking any prescription medication). You may also find that supportive underwear that fits snugly may help with pain relief.

For those who have troublesome symptoms and in particular those with potential fertility issues, management options are as follows:

Embolisation – where special thin metal coils are used to block the abnormal veins
Surgery – where a cut in the groin or scrotum is used to close of the abnormal veins.

Undoubtedly symptoms are best managed by an individual patient-centred approach and some men would prefer surgery and others embolisation. When you are seen in rooms by the IR specialist you can trust that you will be only offered treatment if it is thought to be your best option.

Varicocele Embolisation

Varicocele embolisation is a non-invasive treatment option used to treat enlarged veins in a scrotum. It involves a thin tube introduced via a vein in the neck or groin and navigated to the veins inside the abdomen under x-ray guidance. Once in position special metal coils and sometimes foam is used to close the abnormal veins.

Embolisation is an excellent option as it means a varicocele can be treated without surgery. It does not involve any incisions or cuts on the groin or scrotum and does not need a general or spinal anesthetic. Surgery risks damage to the tube which carries sperm from the testicle. Risks from embolisation are very rare but can include blockage of other normal blood vessels.

Find out more about Varicocele Embolisation.