How common is varicocele and will I require surgery?

Firstly, let’s talk about veins. Veins are vascular structures responsible for delivering blood from various body organs to the heart. For efficient delivery, there are valves along the course of these veins that ensure unidirectional blood flow especially when blood is ascending towards the heart against gravity.

Varicocele is a condition where the veins responsible for delivering blood from the male testicles to the main systemic veins, develop faulty valves. This consequently leads to pooling of blood within the veins surrounding the testicles and eventually their engorgement and dilatation. We asked interventional radiologist Dr Sami Abdelghaffar to answer some questions about varicocele.

Varicocele is quite prevalent and might affect up to 15-20% of the adolescent and adult male population. Luckily not all patients with varicocele develop symptoms which usually manifest as follows:

• Some patients complain of scrotal pain or heaviness that is usually more evident whilst standing and decreases when lying down flat.
• Other patients may start feeling an unusual scrotal swelling which corresponds to the enlarged/engorged veins around the affected testicle.

On many other occasions, varicoceles are accidentally discovered in male patients with infertility while investigating delayed pregnancy with their partners.

If asymptomatic (causing no symptoms), varicocele can be ignored or left untreated, however, once symptoms develop, this prompts the patient to seek medical attention.

Will varicocele always require surgery?

Medical treatment such as painkillers or decongestive pills (e.g. Daflon) aims to alleviate symptoms such as pain rather than treating the condition.

For a long time, surgical management was the only definitive way to treat varicocele by isolating the diseased vein with faulty valves from the testicle. Various surgical techniques can be used such as retroperitoneal, laparoscopic, inguinal, and sub-inguinal approaches. The microsurgical sub-inguinal approach is currently considered the best surgical option with the best results.

What is varicocele embolisation?

A relatively new and modern treatment option has appeared and evolved over the past 2 decades, which is varicocele embolisation. The word embolisation refers to the closing off of problematic body vessels by means of different methods. This is a safe one-day procedure and most patients can return to normal daily activities the same day and resume work the following day, depending on the nature of their job.

This minimally invasive treatment is performed by an interventional radiologist who utilises X-rays to visualise varicoceles without the need to surgically cut through the patient’s skin. This is done via a small nick in the groin or the neck and now in the arm, where a small tube called a catheter is introduced under local anaesthesia. This catheter is advanced under X-ray guidance until it reaches the diseased veins. A dye is injected via the catheter and all the diseased veins can be seen.

Once visualised, the interventional radiologist can use several methods to obliterate the problematic veins. Metallic coils can plug the veins from inside instead of from the outside. Alternatively, a fluid agent (venous sclerotherapy) can be injected inside the veins which lead to their closure. Sometimes both coils and sclerotherapy are used for achieving better results. Once the diseased veins are closed, congestion of the testicular veins is relieved, and blood begins to circulate via alternative normal veins.

Success rates of varicocele embolisation are comparatively close to that of surgery, yet it has the advantage of being safer in terms of major complications and recovery is faster. Research results have shown that treating varicocele in patients with fertility leads to improved semen analysis parameters in about 70% of patients, while 40-60% show an increase in pregnancy rates within 3-4 months.

If untreated, can a varicocele lead to infertility?

Without treatment varicocele, related infertility is unlikely to be resolved. There is always a chance of recurrence of varicocele after various treatment methods, yet treatment can also be repeated successfully in these cases if clinically required.

For more information about treating varicocele, visit Dr Samir Abdelghaffar.