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Varicocele
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A varicocele is an abnormally dilated (enlarged) internal spermatic vein that drains the testicle. It is a very common condition present in 15% of the general male population and about 40% of infertile males. In some cases, varicoceles cause no symptoms and are harmless. However, sometimes, a varicocele can lead to pain or atrophy (shrinkage), or fertility problems. |
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Causes |
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The varicocele occurs when the valves within the veins along the spermatic cord don't work properly. Normally, blood flows into the testicles through an artery, and flows out via a network of tiny veins that drain into a long vein going up through the abdomen. The normal direction of blood flow in this vein is always up, toward the heart. This vein has a series of one-way valves that prevent the reverse flow of blood back to the testicles. Sometimes, when these one-way valves fail, the reverse blood flow stretches and enlarges the tiny veins near the testes to cause a varicocele, a tangled network of blood vessels, or varicose veins. |
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Varicoceles usually occur in the region of the left testicle, most likely because of the position of the left testicular vein. However, a varicocele in one testicle can affect sperm production in both testicles. |
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Symptoms |
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Though typical varicocele symptoms are mild and many do not require treatment, some varicoceles causing pain or atrophy or infertility need treatment. The symptoms include: |
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Pain in the scrotum |
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Heaviness of the testicles |
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Infertility/Subfertility |
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Shrinkage (atrophy) of the testicles |
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Visible or palpable enlarged vein |
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The major symptoms are discussed below. |
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Pain in the Scrotum |
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Pressure may build up in the affected scrotal veins and an aching/dragging pain may be felt when the individual has been standing or sitting for an extended time. Heavy lifting may make varicocele symptoms worse and, in some cases, can even cause varicoceles to form. Usually (but not always) painful varicoceles are prominent in size. |
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Infertility/Subfertility |
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Though it is difficult to be certain if a varicocele is the cause of infertility, there is an association between varicoceles and infertility or subfertility. About 40% of subfertile men were found to have a varicocele. A Varicocele can lead to the following reproductive problems: |
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Decreased sperm count |
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Decreased motility of sperm |
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An increase in the number of deformed sperm |
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Though it is not known for sure how varicoceles contribute to these problems, a common theory is that the condition raises the temperature of the testicles and affects sperm production. According to some estimates, 40% of men with fertility problems, after undergoing varicocele repair, experience a significant improvement in the quality and/or quantity of sperm production. |
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Testicular Atrophy |
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Atrophy or shrinking of the testicles is another symptom of varicoceles. Repair of the varicocele is often recommended when the affected testicle is smaller than the other. |
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Diagnosis |
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A varicocele can be usually detected upon physical examination of the scrotum while the patient is standing. The varicocele feels like a "bag of worms" and disappears or becomes significantly reduced when the patient lies down. Frequently, the backflow of blood can be felt in the scrotal veins. Occasionally, a varicocele may be so prominent that it can be seen through the skin. Often, the testicle on the side of the varicocele is smaller than the other side.
Ancillary diagnostic measures, such as scrotal ultrasonography, thermography, Doppler examination, radionuclide scanning, and spermatic venography are generally used for the detection of varicoceles in patients with a palpable abnormality. This is because only larger varicoceles, which are typically easily palpable, have been clearly associated with infertility. Scrotal ultrasonography is indicated for evaluation of an inconclusive physical examination of the scrotum. Spermatic venography may be useful to demonstrate the anatomic position of refluxing spermatic veins that recur or persist after varicocele repair. |
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Treatment Options |
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There are two approaches to varicocele repair: |
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Surgery |
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Percutaneous embolization |
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Neither of these methods has been proven superior to the other in its ability to improve fertility. |
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Varicocele Surgery |
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Surgical repair of a varicocele may be carried out by various open surgical methods such as retroperitoneal, inguinal and subinguinal approaches, or by laparoscopy. The abnormal veins are identified and interrupted so blood can no longer pool around the testicle. Surgical repair offers the best results. Semen improvement is expected in up to 40% of men. Surgery is performed under general anesthesia on an outpatient basis and generally takes 30-45 minutes to complete. |
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Varicocele Embolization |
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Embolization is a nonsurgical, outpatient procedure that does not require general anesthesia. Light sedation, sometimes called "twilight anesthesia" is used during the procedure; the patient does not lose consciousness. A small tube (catheter) is inserted into a small incision in the groin or neck to block the flow of blood to the varicocele. Using Venography, the varicocele is highlighted on x-ray to visually guide the catheter into the varicocele vein. The catheter is then used to push tiny coils into place to block the blood flow to the dilated vein. This eases the pressure, reduces enlargement, and restores normal circulation. The tube is removed and no stitches are needed. Normal activity is usually resumed within 2 days. |
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Management of Varicocele Induced Infertility |
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Based on the severity of sperm abnormalities associated with a varicocele, intrauterine insemination (IUI) can be opted for. However, in severe cases of male infertility, ICSI (intracytoplasmic sperm injection) is the best option. |
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