What is Varicocele? Symptoms and Surgery of Varicocele

Varicocele is a health problem that affects men and is seen worldwide. It does not pose a life-threatening risk, but it can affect an individual's comfort and may be considered a risk factor, especially for those wishing to have children. Varicocele can be attributed to nearly 40% of men experiencing infertility.

What is Varicocele?

The male reproductive system is responsible for the production, storage, and transportation of sperm. Sperm is the male reproductive cell that fertilizes the egg in women. In men, sperm is stored in units called testes, which synthesize the hormone testosterone. A healthy male typically has two testes. The scrotum is the pouch that holds the testes. Sperm matures in a coiled tube (epididymis) located behind each testis. From the epididymis, sperm travels through a tube known as the vas deferens to the prostate. The prostate is a gland located at the front of the intestines, just below the bladder, and surrounds the exit of the bladder. It is responsible for producing the fluid that protects sperm.

When ejaculation occurs, the sperm and the protective fluid secreted by the prostate form semen, which is expelled through the urethra at the tip of the penis. For healthy sperm production and storage, the temperature in the testes must be lower than the body's temperature. Before blood reaches the testes, there are vessels in the testicular artery that act as a countercurrent heat exchanger, carrying oxygen-poor blood from the testes. These vessels, known as the pampiniform plexus, help maintain the temperature in the testes, contributing to the production of quality sperm. Varicocele is a varicose-like formation that develops due to the enlargement of the pampiniform plexus. It generally does not cause serious issues and is considered harmless. However, in some cases, it can lead to pain or shrinkage of the testes. The dilation of the veins in the scrotum can cause overheating of the testes, leading to a decrease in sperm production and a decline in sperm quality.

What are the Symptoms of Varicocele?

Varicocele typically progresses without showing any symptoms. Although it is not considered a serious problem, it can cause variations in sperm quality and quantity, especially in men wishing to conceive. Varicocele investigations are often conducted in men facing unexplained infertility. Symptoms of varicocele may include:

• Varicocele usually develops unilaterally. Due to the high prevalence of oxygen-rich blood in the scrotal veins, a soft swelling can often be observed on the left side, above the testis. This swelling can present itself as a worm-like structure due to the enlargement and twisting of the veins.
• Persistent dull pain or a feeling of heaviness in the testis, scrotum, or groin (often alleviated when lying down).
• Pain and discomfort that worsen in hot weather or after exercise.
• Shrinkage of the affected testis.

To diagnose varicocele, a urologist will review the patient's medical history, gather information about symptoms from the patient, and conduct a physical examination. If varicocele is suspected, the following tests may be requested:

• Pelvic Ultrasound: This imaging test is performed to examine the vessels in the testes in detail. The appearance of the vessels is examined using an ultrasound device on the skin of the testis.
• Semen Analysis: Varicocele can affect sperm quality and quantity. The sperm characteristics are investigated from the patient's semen.
• Blood Test: In cases of varicocele, the patient may experience changes in FSH (follicle-stimulating hormone) and testosterone levels. These changes can be detected through blood tests, leading to a diagnosis of varicocele.

If varicocele is present, its severity is graded as follows:

• Grade 0: This is the testicular vessel enlargement detected by ultrasound. The doctor does not feel the vessel enlargement during a physical examination, but varicocele can be mentioned based on ultrasound findings.
• Grade 1: During the physical examination for varicocele, the doctor uses a method called the Valsalva maneuver. The patient is asked to take a deep breath and try to exhale while keeping their mouth and nose closed. If swelling is observed in the vessels during this maneuver, it can be classified as first-degree varicocele.
• Grade 2: If swollen vessels are observed in the testis even without performing the Valsalva maneuver, a diagnosis of second-degree varicocele is made.
• Grade 3: Swollen vessels in the testes are visibly apparent and can be easily felt during the doctor's physical examination.

What Causes Varicocele?

There is no specific risk factor for the development of varicocele, and it is not possible to pinpoint a clear cause. Each testis is located within the spermatic cord, which consists of the testicular nerves, the vas deferens (the channel that transports sperm), the testicular artery, and the veins. This vascular stalk helps keep the testes stable. Healthy veins have one-way valves. These valves, which function to open and close, help move blood from the testes to the scrotum and back to the heart. In some cases, these valves may not function properly, leading to blood pooling and vein dilation. Over time, dilated veins can cause varicocele. Possible factors that can lead to vein dilation include:

• The veins of the left testis are positioned vertically. Blood can forcefully spurt from the vertically angled veins, causing valve malfunction. This can lead to blood pooling and gradual dilation and twisting of the veins.
• The development of any lesion in the right or left testicular veins, or compression of the veins by nearby organs such as the intestines, can cause blockage in the testicular veins. Over time, this blockage can damage the valves, leading to blood pooling and vein dilation.
• Nutcracker Syndrome is a condition caused by the compression of the left renal vein between the aorta and the superior mesenteric artery (intestinal artery). This compression can cause stronger blood flow to the left testicular vein, leading to damage to the valve system and vein dilation.

Varicocele can occur at almost any age and is usually a congenital condition. In most cases, it is noticed during adolescence and can prevent the proper development of the testes.

How is Varicocele Treated?

The treatment for varicocele varies depending on the degree of vein dilation. In cases of low-grade varicocele, the following options may be recommended by a doctor:

• If varicocele does not cause discomfort to the patient and there are no issues with sperm quality, treatment may not be necessary.
• Certain activities that cause discomfort in the testes should be avoided. For example, standing for long periods or exercising can cause pain and discomfort in the testes. In this case, the doctor may recommend wearing tight underwear or a supporter garment designed to keep the testes stable.
• Applying ice may be suggested to reduce pain and discomfort in the testes. Cold can help constrict the dilated veins. Instead of applying ice directly to the skin, you can wrap ice in a clean towel and apply it to the painful testes for 15 minutes.
• For advanced cases, particularly those affecting sperm quality, the doctor may recommend treatments such as varicocele surgery or varicocele embolization.

How is Varicocele Surgery Performed?

Varicocele surgery, known as varicocelectomy, is a surgical procedure performed in a hospital setting under general or local anesthesia. In this surgery, conducted by a urologist, the doctor accesses the abdomen or pelvis surgically. The enlarged veins are cut, and their ends are tied off. Through a procedure known as microsurgery, which is performed under a microscope, the dilated blood vessels are closed, allowing blood to flow through other vessels. Another method used in the treatment of varicocele is varicocele embolization. In this method, the patient’s armpit or groin is anesthetized, and a thin sheath is placed inside the vein. Using an angiography device, the dilated veins are identified. Then, the enlarged veins are closed off using special wires.

What Should Be Considered After Varicocele Surgery?

During the week following varicocele surgery, it is important for the patient to rest. The surgical area must be protected from impacts, and regular dressing changes should be performed. During this time, the patient is advised not to take showers. Depending on the condition of the surgical wound, your doctor may decide when to remove the dressings and when you can shower. In the month following the surgery, lifting heavy loads and engaging in strenuous sports activities can prolong the recovery process. It is normal to see swelling in one or both testes during the first few days after the procedure. Fluid accumulation around the testes, known as a hydrocele, may be observed. In this case, a second surgical procedure, referred to as hydrocele surgery, may be necessary.

To protect sexual health and prevent circulatory system issues in older age, it is important to have regular check-ups. Individuals of reproductive age who have risk factors or symptoms of varicocele are advised to consult a specialist promptly.