eMedicine Specialties > Urology > Common Problems of the Testicle
Varicocele: Treatment
Updated: Jul 28, 2009
Treatment
Medical Therapy
A varicocele is an anatomic abnormality that can impair sperm production and function. No effective medical treatments for varicoceles have been identified. While some investigators are evaluating the role of antioxidants for the treatment of elevated levels of reactive oxygen species, this treatment approach is still experimental.
Surgical Therapy
The primary form of treatment for varicoceles is surgery. Because of the potential to cause significant testicular damage, evaluate the varicocele during the physical examination. The presence of a varicocele does not mean surgical correction is necessary.
The ultimate goals of varicocele repair should include occlusion of the offending varicosity with high success, preservation of arterial flow to the testis, and the minimization of patient discomfort and morbidity. Viable options for repair include radiographic obliteration and surgical repair of various approaches. The efficacy of the myriad techniques is nearly equivalent. Therefore, special attention must be paid to the morbidity of the individual procedure and the expertise of the operating surgeon.
Preoperative Details
Perform varicocele surgery in an outpatient setting using one of various anesthetics (eg, general, regional, local). A general anesthetic provides maximal patient comfort.
Intraoperative Details
The 3 most common surgical approaches used to correct a scrotal varicocele include inguinal (groin), retroperitoneal (abdominal), and infrainguinal/subinguinal (below the groin) approaches. With all 3 approaches, all abnormal veins are tied permanently to prevent continued abnormal blood flow (see Image 2). Avoid the vas deferens and the testicular artery during the surgery.
Incision for an inguinal approach to varicocele repair.
The inguinal and subinguinal approaches are those most commonly used by the vast majority of adult urologists and infertility specialists. The familiar anatomy, low morbidity, and high efficacy make these approaches almost ideal. Inguinal ligation is achieved by incising the inguinal canal down to the external inguinal ring. After cord isolation, the testicular artery is preserved and the veins of the cord are ligated and divided.
The subinguinal approach is performed in a similar fashion, but access is achieved through an incision at or near the pubic tubercle that obviates the opening of the external oblique aponeurosis. The advantages of subinguinal varicocele ligation, especially with use of magnification, include decreased pain and easier access to the spermatic cord, especially among obese men and those with a history of inguinal surgery. However, at this level, a greater number of veins are present, especially periarterial anastomosing veins, that make subinguinal ligation technically challenging.
The use of the microsurgical technique has advanced the surgical treatment of this disorder by allowing optimal visualization. While the approach to cord isolation is no different, the 6-25X magnification facilitates the identification of small anastomosing veins that might otherwise be missed. Furthermore, the risk of testicular ischemia and testis atrophy due to inadvertent ligation of the testicular artery is greatly reduced with this improved visualization. This risk of arterial ligation can be further reduced by using a mini-Doppler ultrasound probe (Vascular Technology, Inc. [VTI] 20-MHz microvascular Doppler) with the use of a topical vasodilator.
The retroperitoneal approach offers great proximal control of the spermatic vein near its insertion at the renal vein, and this approach may be accomplished laparoscopically. This technique, however, carries a high recurrence rate (nearly 15%) due to inguinal and retroperitoneal collateral veins, failure to ligate fine periarterial veins when the testicular artery is preserved, an inability to preserve lymphatics, and potential hydrocele formation when the artery and vein are ligated en bloc. This approach to varicocele ablation remains popular among pediatric urologists.
Percutaneous embolization represents the least invasive means of varicocele repair. The internal spermatic vein is accessed primarily via cannulation of the femoral vein through a retrograde approach with subsequent balloon and/or coil occlusion of the varicocele. The advantages of percutaneous embolization include preservation of the testicular artery and the relatively noninvasive nature of the technique. However, the percutaneous approach can be fraught with troublesome access to the vein, and postoperative complications such as contrast allergies, arterial injury, thrombophlebitis, and coil migration are uncommon but tangible risks. This approach is often reserved for recurrent varicoceles after open surgical repair.
Postoperative Details
Patient instructions
- Varicocele surgery is usually performed in an outpatient setting (ie, day-surgery unit). Patients may return to normal nonstrenuous activities (eg, work) after 2 days.
- All outer dressings are removed 48 hours after surgery. The small strips of tape (Steri-Strips) are left in place for 7-10 days before removal.
- Inform patients that bathing or showering is permitted 48 hours after surgery.
- A normal, well-balanced diet can be resumed when patients return home. Advise patients to start with fluids and gradually return to solid foods.
- Prescribe pain medication and advise patients to take as directed. After 2 days, patients may take nonprescription acetaminophen (eg, Tylenol) or ibuprofen (eg, Advil, Motrin) to relieve discomfort.
- Patients can engage in normal, nonstrenuous activity when they feel up to it. If activity causes discomfort, it should be discontinued. Patients can resume more strenuous activities (eg, weightlifting, jogging) after 2 weeks.
- Advise patients to refrain from intercourse for 1 week.
Common discomforts and symptoms that do not require medical attention
Patients may experience some postoperative discomfort. Complications are rare. Common discomforts or symptoms do not require a doctor's attention and may include the following:
- Minor bruising and slight discoloration may appear around the groin incisions but are self-limited.
- The sensation of hardness around and beneath the incision site resolves in approximately 3 weeks.
- The slight redness and tenderness around the incision from the normal healing process resolves in a few days.
- A very small amount of thin, clear, pinkish fluid drains from the incision for a few days after the procedure. Advise patients to keep the area clean and dry.
- A sore throat, headache, nausea, constipation, and general body ache occur because of the surgical procedure and anesthetic. Advise patients that these problems resolve within 24 hours.
Postoperative complications that require prompt medical attention
- If wounds become infected (usually 3-5 d after surgery), antibiotics may be necessary. Wounds can become warm, swollen, red, and painful, with significant drainage from the incision site, and patients may develop fever.
- Hematomas may form. Extreme discoloration around the abdominal incisions results from bleeding underneath the skin, which causes throbbing pain and bulging wounds.
Follow-up
Check the patient's semen 3-4 months after surgery. Because spermatogenesis requires approximately 72 days, any effects from the varicocele repair on semen analysis results are delayed.
Patient instructions
- The patient returns to the clinical office for a wound evaluation in approximately 7-10 days.
- Schedule a follow-up examination for a wound check and varicocele examination for 8 weeks after surgery.
- Schedule a semen analysis and consultation for 4 months after surgery. At this time, the timing of subsequent appointments can be discussed.
For excellent patient education resources, visit eMedicine's Men's Health Center. Also, see eMedicine's patient education articles Understanding the Male Anatomy and Testicular Pain.
Complications
The prevalence of adverse effects following varicocele repair is remarkably low. Hydrocele or increased fluid around the testicles occurs in 2-5% of patients. Successful surgery often increases conception rates in infertile couples. The overall recurrence rate for varicoceles has been reported as high as 10%.
Injury to the testicular artery has been reported in 0.9% of microsurgical varicocele repairs. This incidence may be higher when optical magnification is not used for varicocele repair. Because the testis typically has additional arterial supplies from the vasal and cremasteric arteries, testicular atrophy is uncommon (5%) after division of the testicular artery. Smaller atrophic testes may be at greater risk for accidental testicular artery injury because of the smaller size of the artery in these cases.
In a patient in whom a varicocele is first identified during a vasectomy reversal, varicocelectomy at the time of the vasectomy reversal is controversial. Delaying the varicocelectomy preserves some venous return in these patients and avoids possible injury to the testicular artery. Consider varicocele repair 6 months later, after new vascular channels form.
More on Varicocele |
| Overview: Varicocele |
| Workup: Varicocele |
 Treatment: Varicocele |
| Follow-up: Varicocele |
| Multimedia: Varicocele |
| References |
| Further Reading |
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References
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Further Reading
Clinical trials
Keywords
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