eMedicine Specialties > Urology > Common Problems of the Testicle

Varicocele

Author: Wesley M White, MD, Chief Resident, Department of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine, University of Tennessee Medical Center
Coauthor(s): Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center; Joe D Mobley III, MD, MPH, Chief Resident Physician, Department of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine/University of Tennessee Medical Center
Contributor Information and Disclosures

Updated: Jul 28, 2009

Introduction

A varicocele is a dilatation of the pampiniform venous plexus and the internal spermatic vein. Varicocele is a well-recognized cause of decreased testicular function and occurs in approximately 15-20% of all males and in 40% of infertile males. Understanding the significance of this anatomic abnormality in the infertile patient requires a brief review of the history, background, and current concepts of functional anatomy, as well as the methods and results of surgical repair.

History of the Procedure

Varicocele was first recognized as a clinical problem in the 16th century. Ambroïse Paré (1500-1590), the most celebrated surgeon of the Renaissance, described this vascular abnormality as the result of melancholic blood. Barfield, a British surgeon, first proposed the relationship between infertility and varicocele in the late 19th century. Shortly thereafter, other surgeons reported that varicocele is associated with an arrest of sperm secretion and the subsequent restoration of fertility following repair. Through the early 1900s, reports by other surgeons continued to describe the association of varicocele with infertility.

In the 1950s, after a report of fertility following varicocele repair in an individual known to be azoospermic (ie, without sperm), the idea of surgically correcting varicoceles as a clinical approach to certain kinds of male infertility gained support among American surgeons. Research continued, leading to many published studies that associated varicoceles with impaired semen quality.

In these studies, researchers documented a recurrent pattern of low sperm count, poor motility, and predominance of abnormal sperm forms; this became known as the stress pattern of semen. Although not synonymous or specific to varicocele, the term suggests early evidence of testicular damage. Urologists then began to assess male infertility through the study of sperm, which are evaluated for count, percentage of motile forms, forward movement or motility, and morphology (shape or form); the semen is also evaluated.

Problem

A varicocele is a dilatation of the pampiniform venous plexus within the scrotum. Approximately 15-20% of the healthy fertile male population is estimated to have varicoceles; however, 40% of infertile men may have them. How a varicocele impairs sperm structure, function, and production is unknown, but researchers believe it interferes with testicular thermoregulation.

Frequency

Although varicoceles appear in approximately 20% of the general male population, they are much more common in the subfertile population (40%). In fact, scrotal varicoceles are the most common cause of poor sperm production and decreased semen quality. Varicoceles are easy to identify and to surgically correct.

Etiology

Varicoceles are much more common (approximately 80-90%) in the left testicle than in the right because of several anatomic factors, including (1) the angle at which the left testicular vein enters the left renal vein, (2) the lack of effective antireflux valves at the juncture of the testicular vein and renal vein, and (3) the increased renal vein pressure due to its compression between the superior mesenteric artery and the aorta (ie, nutcracker effect). Also of importance is that a one-sided varicocele can often affect the opposite testicle. Up to 35-40% of men with a palpable left varicocele may actually have bilateral varicoceles that are discovered upon examination. A 2004 study by Gat et al suggested that up to 80% of men with a left clinical varicocele had bilateral varicoceles revealed by noninvasive radiologic testing.¹

Varicoceles vary in size and can be classified into the following 3 groups:

• Large - Easily identified by inspection alone
• Moderate - Identified by palpation without bearing down (Valsalva maneuver)
• Small - Identified only by bearing down, which increases intra-abdominal pressure, thus impeding drainage and increasing varicocele size

Pathophysiology

Several theories have been proposed to explain the harmful effect of varicoceles on sperm quality, including the possible effects of pressure, oxygen deprivation, heat injury, and toxins.

Despite considerable research, none of the theories has been proved unquestionably, although an elevated heat effect caused by impaired circulation appears to be the most reproducible defect. Supporting this hypothesis is the fact that a varicocele created in an experimental animal led to poor sperm function with elevated intratesticular temperature. Regardless of the mechanism of action, a varicocele is indisputably a significant factor in decreasing testicular function and in reducing semen quality in a large percentage of men who seek infertility treatment.

Although unproved, a varicocele may represent a progressive lesion that can have detrimental effects on testicular function. An untreated varicocele, especially when large, may cause long-term deterioration in sperm production and even testosterone production. If an infertile male has bilateral varicoceles, both are repaired to improve sperm quality.

Presentation

A patient with a varicocele is usually asymptomatic and often seeks an evaluation for infertility after failed attempts at conception. He may also report scrotal pain or heaviness. Careful physical examination remains the primary method of varicocele detection. An obvious varicocele is often described as feeling like a bag of worms. Scrotal examination for varicocele should be a facet of the standard urologic physical examination because of the potential for varicoceles to cause significant testicular damage. The presence of a varicocele does not mean that surgical correction is a necessity.

Indications

Reasons for surgical correction of a diagnosed variocele include relieving significant testicular discomfort or pain not responsive to routine symptomatic treatment, reducing testicular atrophy (volume <20 mL, length <4 cm), and addressing the possible contribution to unexplained male infertility. A varicocele may cause progressive damage to the testes, resulting in further atrophy and impairment of seminal parameters.

The Male Infertility Best Practice Policy Committee of the American Urological Society recommends that varicocele treatment should be offered to the male partner of a couple attempting to conceive when all of the following are present:²

• A varicocele is palpable.
• The couple has documented infertility.
• The female has normal fertility or potentially correctable infertility.
• The male partner has one or more abnormal semen parameters or sperm function test results.

In addition, adult men who have a palpable varicocele and abnormal semen analyses findings but are not currently attempting to conceive should also be offered varicocele repair.

A scrotal varicocele is the most correctable factor in a male with poor semen quality; therefore, varicocele repair should be considered a viable choice for appropriately selected individuals and couples with otherwise unexplained infertility because varicocele repair has been shown to improve semen parameters in most men and possibly improve fertility; in addition, the risks of varicocele repair are small.

The results of treating varicoceles in adolescents are not as clear as the results of treating varicoceles in adults. Although varicoceles first become apparent in adolescence, their natural history and its timeline for the onset of detrimental effects on testicular function remain unclear. Varicoceles occur in approximately 10-15% of the fertile male population, but not all varicoceles impair sperm function, overall semen quality, or fertility.

Important determinations to be made regarding varicoceles in adolescents are whether (1) the varicocele is a progressive lesion and (2) early repair of the varicocele would prevent infertility.

In 1977, Lipshultz and Corriere suggested that varicoceles were associated with testicular atrophy that was progressive with age.³ They also observed that testicular biopsy specimens taken from prepubertal boys with varicoceles already revealed histologic abnormalities. However, Diamond et al from Harvard have challenged this concept.⁴

In 1987, Kass and Belman were the first to demonstrate a significant increase in testicular volume after varicocele repair in adolescents.⁵ Although Kass and Belman noted catch-up growth, they did not study semen parameters. Collecting a semen sample from an adolescent is not always easy; consequently, studying the effects of a varicocele and the benefits of treatment is difficult.

The indications for repairing varicoceles in adolescents include the presence of significant testicular asymmetry (>20%) demonstrated on serial examinations, testicular pain, and abnormal semen analysis results. Very large varicoceles may also be repaired; however, in the absence of atrophy, this indication is relative and controversial. Young men with varicoceles but normal ipsilateral testicular volume should be offered follow-up monitoring with annual objective measurements of testicular volume, semen analyses, or both.

Relevant Anatomy

The testes are the paired male genital organs that contain sperm, cells that produce and nourish sperm (spermatogonia and Sertoli cells, respectively), and cells that produce testosterone (Leydig cells). The testes are located in a sac called the scrotum. The epididymis is a small tubular structure attached to the testes that serves as a storage reservoir wherein sperm mature.

Sperm travel through the vas deferens, which connects the epididymis to the prostate gland. The vas deferens is in the scrotum and is part of a larger tissue bundle called the spermatic cord. The spermatic cord contains the vas deferens, blood vessels, nerves, and lymphatic channels.

The pampiniform plexus is composed of the veins of the spermatic cord. These veins drain blood from the testes, epididymis, and vas deferens and eventually become the spermatic veins that drain into the main circulation of the kidneys. The pampiniform venous plexus may become tortuous and dilated, much like a varicose vein in the leg. In fact, a scrotal varicocele is simply a varicose enlargement of the pampiniform plexus above and around the testicle. Two other veins, the cremasteric and the deferential, also drain blood from the testicles; however, they are rarely involved in the varicocele process.

The image below illustrates the basic anatomy.

Contraindications

Opinions vary regarding the value of repairing subclinical varicoceles in infertile men, but most experts do not recommend it. In addition, discovery of a varicocele at the time of vasectomy or vasectomy reversal is a relative contraindication to immediate repair. A 6-month delayed repair is recommended to allow the development of collateral vessels in order to decrease the chance of vascular compromise to the testicle.

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