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Varicoceles: Should they be fixed or is it all ado about nothing?

There are numerous disorders of the male reproductive tract. The most common disorders are hernias, varicoceles, infections of the reproductive tract and occasionally cancer. The majority of abnormalities of the male groin appear as masses which may be painless or painful. A common cause of swelling in the groin area in young adult males is varicoceles. Varicoceles are abnormal enlargements (dilations) of the pampiniform plexus of veins within the scrotum. They are similar to varicose veins of the leg, and often become evident after puberty. They become most evident in the young adult male and usually enlarge with time. Varicoceles are more common on the left groin than the right. This is due to the anatomical differences in the origin of the testicular veins. Frequency The reported incidence of varicoceles is about 1 in every 20-30 males. Varicoceles are present in about 10-20% of the male population. However, of those males who are being worked up for their infertility, at least 40% of these individuals show evidence of varicoceles. All racial or ethnic groups are prone to the development of varicoceles. Not all males are symptomatic and many do not even know they have the condition. In a number of males, the finding of a varicocele is an incidental finding. Varicoceles are not evident in childhood but do become more conspicuous in the 2nd and 3rd decade of life. In the majority of cases, it is the left testicle which is affected. Even though only one testicle may be affected by a varicocele, this may be adequate to decrease sperm product and cause infertility. What cause varicoceles? There is a large group of veins running from the scrotum and testes into the groin. Any blockage of these veins will result in swelling of the veins in the groin. The group of veins enlarges when the outflow is blocked can lead to dilatation and enlargement of the vein mass and is known as a varicocele. The veins may block because of several reasons including a. abnormal valves b. defective valves c. abnormal anatomy of the vein entry into the scrotum d. tumors (both malignant and benign) What are the symptoms of varicoceles? The majority of individuals who have been diagnosed with a varicocele have no varicocles symptoms. A few individuals may complain of a swelling in the groin area. They will complain that the mass is often present when standing up and disappears whey they lie down. When lying down the veins empty of blood and thus the swelling disappears. Others may complain of an odd ache in the groin. The odd ache and discomfort is more pronounced after a long days’ work, heavy exercise or lifting weights. All varicoceles worsen with time in terms of growth and enlargement. How are varicoceles diagnosed? The majority of individuals are diagnosed with a varicocele on a routine exam for another illness. In others, the varicocele is discovered when the individual is being worked up for infertility. The rest of the individuals have the diagnosis made after having developed symptoms of pain or swelling in the groin. A varicocele is easily identified on a physical exam. The varicocele feels like a “bag of worm” and enlarges when the individual stands up. All varicoceles disappear when the individual lies down. So it is essential that the physician examines the patient in both positions. A few individuals may have a very small varicocele which may not be obvious on a physical exam. In these individuals an ultrasound will be diagnostic. The ultrasound may also discover the cause of the varicocele. It is the very rare individual who requires any further radiological study to make a diagnosis of a varicocele. No blood work is required in the diagnosis of a varicocele. There is some consensus among surgeons that the routine use of ultrasound to identify the very small varicocele is not only not necessary, but is expensive and wasteful. A number of studies have shown that these very small varicoceles are clinically not important and are harmless. What are the treatment options for varicoceles? There is a lot of debate whether varicoceles require any treatment. No medical therapies are available for either treatment or prevention; however analgesic agents may alleviate associated pain when present. Some doctors claim that no treatment is required. Others claim that treatment may benefit individuals who are infertile and have symptoms. The treatment involves removal of the vein mass which is causing the enlargement and infertility. The timing of the varicocele is also debated. Some doctors claim that even though varicoceles may be detected in adolescence, the treatment can wait until the individual has any symptoms or is getting married. Others recommend varicocele repair in adolescence only if there is evidence of pain, testicular atrophy or if the sperm count is altered. Surgery Treatment There are two main approaches to the treatment of a varicocele. Treatment of varicoceles varies from open surgery to refined radiological destruction techniques. Most urologists recommend the radiological techniques after the open surgery techniques have failed. Surgical Repair The surgery is done under anesthesia and is an outpatient procedure. There are various surgical techniques and all involves tying or removal of the large vein complex. Most surgeons recommend that the wearing of high magnification loops allows for better visualization and identification of these venous clumps. Today, smaller micro invasive procedures have also been developed which only require 1-2 small incisions. However, these refined laparoscopic procedures also have the potential for a higher rate of complications than the open method. The procedure may be done under local, spinal or general anesthesia. Radiological embolization A few individuals who have a recurrent of a varicocele or complex varicoceles may undergo a procedure known as radiological embolization. This is an outpatient procedure done in the radiology suite. Local anesthetic is infiltrated on the opposite groin and a small needle is placed into a large vein in the groin or neck. This procedure is performed by radiologists using a special tube that is inserted and directed to the varicocele. After radiographic visualization of the enlarged veins of the pampiniform plexus, coils or balloons are used to block the veins. The blockage of the veins leads to their collapse as they can’t fill with blood anymore. The procedure is done under mild intravenous sedation or local anesthetic and usually takes several hours to complete. Complications may include varicocele persistence/recurrence, coil migration and complications at the venous access site. This technique is not widely available at all medical centers. For those who undergo a radiological embolization, the recovery period is also short and most individuals recover within 24-48 hours. The pain is very mild and like the surgery, individuals are asked to refrain from heavy exercise and lifting for 2 weeks. Unlike surgery, the recurrence rates after embolization are much higher. What can be expected after treatment? The surgery for varicocele treatment is considered minor in nature and the incision is small. The majority of individuals recover rapidly. The pain is easily controlled with over the counter pain medications and only lasts 24 hours. All patients are asked to refrain from strenuous exercise and heavy lifting for 2 weeks. The majority of individuals can return to work in 48 hours. The surgeon will always recommend a follow up appointment in 1-2 week after the surgery. At the follow up appointment, the sperm is analyzed. Semen analyses are typically obtained at three to four month intervals after the procedure. Improvement is often seen within six months, but may not be observed until one year postoperatively. The majority of individuals who undergo the open procedure do well and only have a recurrence rate of 1%. Results All the operative techniques show a good response in the short term, but the recent microsurgical techniques have the fewest complications and the fastest recovery. Despite the advent of newer laparoscopic techniques and better instruments, this technique has not been found to be superior to the open surgical techniques. The short term results are the same as the open surgery. Today, the majority of urologists agree on one thing; only clinically visible varicoceles should be treated. The varicoceles which are small and only identified by ultrasound should be observed. No one has shown that repairing these varicoceles improves the fertility rates. For the symptomatic and large varicoceles, there is some evidence (depending on whom you believe), that pregnancy rates are improved in the previously sterile male. In an era where money and medicine have become a business, the surgeons always claim to have great success with everything they do-so be informed and ask questions. Complications of surgery There is no surgery which is risk free and if a surgeon tells you that he has no complications, seek another surgeon. There are a few minor risks of surgery which are important to know and understand. In about 1-3% of cases, a small amount of watery fluid may accumulate around the testis (hydrocele). This fluid is harmless and not painful. In the majority of cases, the fluid will disappear in a few weeks. The occasional patient may require a needle aspiration to remove the fluid. Scrotal support is highly recommended after surgery to decrease this complication. Other complications resulting from either open or laparoscopic approaches are rare, but include varicocele persistence/recurrence, hydrocele formation and injury to the testicular artery. Recurrence of the varicocele is an ever present risk. If the surgeon fails to remove or ligate all the veins responsible, there is a good chance of a varicocele recurring. It occurs in at least 10% of individuals who have varicocelectomy. In the very rare case, the tubes that transport the sperm can be injured during the surgery and render the individual sterile. This major complication is difficult to correct, but can be done. Self-care When a varicocele is diagnosed, basic home care should include wearing of a scrotal support, avoiding strenuous exercise and heavy lifting. There are no medications, herbs of spices to treat this condition. Pain can be relieved by over the counter medications. Does varicocele surgery improve fertility? There is absolutely no direct correlation between the presence of a varicocele and infertility. There is no doubt that about 40% of individuals who undergo investigation for infertility have been found to have varicoceles. But one has to know that there are many more individuals with varicoceles who go on to have normal sperm and have satisfactory pregnancy with their spouse. There are also many men who undergo varicocele surgery and yet fail to have normal sperm counts. The questions remains, “what should one do with varicoceles”. There is no question that incidentally discovered varicoceles or varicoceles that produce no symptoms can be safely observed. All the data about testicular atrophy and decline in sperm counts are unproven and hypothetical facts put out by unscrupulous surgeons. Many men live their entire lives with varicoceles and do so without any undue problems. Varicoceles continue to generate controversy among fertility experts. Despite conflicting evidence from various clinical studies, all the trials still recommend the surgical treatment of clinical varicoceles in men with infertility. However, it is incumbent on the surgeon to discuss the pros and cons of surgery for varicocele. A second opinion is not always a bad idea