Varicocele is a mass of enlarged veins that develops in the spermatic cord, which leads from the testes (testicles) up through the inguinal canal (passageway in the lower abdominal wall) to the circulatory system. The spermatic cord is made up of blood vessels, lymphatic vessels, nerves, and the vas deferens (duct that carries sperm from the body). If the valves that regulate bloodflow from these veins become defective, blood does not circulate out of the testicles efficiently, which causes swelling in the veins above and behind the testicles.

A varicocele can develop in one testicle or both, but in about 85% of cases it develops in the left testicle. The left spermatic vein drains into the renal vein between the superior mesenteric artery and the aorta; these two arteries can compress the renal vein and thus impede bloodflow from the spermatic vein. The right spermatic vein drains into the vena cava (the vein that returns blood to the heart) and develops varicocele less often. A unilateral (one-sided) varicocele can affect either testicle.

Because of the impaired circulation of blood created by a varicocele, the blood does not cool as it does in a normal vein. The increased temperature of the blood raises the temperature of the testes, which is believed to contribute to infertility, as heat can damage or destroy sperm. The raised temperature may also impede production of new, healthy sperm.

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Incidence of varicocele is 10-20% and is highest in men between the ages of 15 and 25. The sudden appearance of varicocele in an older man may indicate a renal tumor blocking the spermatic vein.

Approximately 40% of infertile men have a varicocele and among men with secondary infertility — those who have fathered a child but are no longer able to do so — prevalence may be as high as 80%.

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A varicocele develops when the valve that regulates bloodflow from the vein into the main circulatory system becomes damaged or defective. Inefficient blood flow causes dilation (enlargement) of the vein.

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Most men who have a varicocele have no symptoms. Asymptomatic (symptom-free) cases are often diagnosed during a routine physical examination. Signs and symptoms may include the following:

• Ache in the testicle
• Atrophy (shrinkage) of the testicle(s)
• Feeling of heaviness in the testicle(s)
• Infertility
• Palpably (evident to the touch) enlarged vein
• Visibly enlarged vein

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Large varicoceles may be seen with the naked eye. Medium-sized varicoceles may be detected during physical examination by palpating (feeling) the area. A patient suspected of having a varicocele should be examined while standing up, as a varicocele is more prominent in this position than in the supine (lying down, face up) position. Small varicoceles may be discovered by a physician using one of the following procedures.

• Doppler ultrasonography uses ultrasound echos to detect the characteristic sound of the backflow of blood through the valve.

• Thermography uses infrared sensing technology to detect pockets of heat caused by pooled blood.

• Venogram is an outpatient procedure performed under local anesthesia. The physician makes a small puncture in the groin and then injects a special dye into the spermatic vein. The dye in the bloodstream enables the physician to see the anatomy in the vein on x-ray and detect the presence of a very small varicocele.

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If the patient is asymptomatic or the symptoms are mild and infertility is not an issue, the condition can be managed by wearing an athletic supporter or snug-fitting underwear to provide the scrotum with support.

Surgery
If the varicocele causes pain or atrophy, if it damages the testicle(s), or if the condition is causing infertility, surgery may be recommended. Most varicoceles can be corrected through a surgical procedure called varicocelectomy (surgically "tying off" the affected spermatic veins). The following methods are used.

Surgical ligation (tying off) usually requires general (controlled state of unconsciousness) or reginal anesthesia. In this procedure, a 2- to 3-inch incision is made in the groin or lower abdomen, the affected veins are located visually, and the surgeon cuts the veins and ties them off above the varicocele to reroute the blood through unaffected veins. A transinguinal (groin) incision is commonly used and a retroperitoneal (lower abdomen) incision is used in patients with scar tissue from a prior varicocelectomy or hernia repair. Surgery can be performed on an in- or outpatient basis. The patient typically can resume light activity within a week and strenuous activity in about 6 weeks.

Embolization is a nonsurgical procedure that takes about an hour and a half. A catheter (small tube) is inserted into a small incision in the groin to block the flow of blood to the varicocele. Venography is used to highlight the varicocele on x-ray and to visually guide the catheter. The catheter is then used to push tiny coils into place to block the blood flow to the dilated vein. This eases the pressure, reduces enlargement, and restores normal circulation. Light sedation, sometimes called "twilight anesthesia," is used during the procedure; the patient does not lose consciousness. Stitches are not needed. Normal activity is usually resumed within 2 days.

Laparoscopy is a technique in which the surgeon inserts a tiny camera attached to a long cylindrical tube into the abdominal cavity through a small incision. Using the camera to locate the varicocele, the surgeon then inserts other instruments through the same incision to isolate and tie off the dilated veins. This technique requires a smaller incision than surgical ligation and is sometimes regarded as less invasive. The laparoscope, however, can sometimes damage abdominal organs, which is not a risk factor in open surgery. The procedure takes about 2 hours and recovery about 2 days.

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Between 5% and 20% of patients experience a recurrence. In such cases, the procedure usually is repeated. Another 2% to 5% develop a condition called hydrocele, a fluid-filled cyst that forms around the testicle. Minor surgery is used to correct this problem.

About 50% of men who undergo varicocelectomy to correct infertility father children within the first year. It takes about 90 days for a sufficient quantity of new sperm to be produced to permit fertilization. Semen analysis usually is done at 3- and 6-month intervals after the operation.

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