WHAT IS VARICOCELE?
Testicles are located in an organ called scrotum within the body. VARICOCELE is a varicosis disease which appears as a result of advanced dilatation and curve increase of veins carrying the venous blood of testicles into the heart (pampiniform plexus veins).
Varicocele is more frequent at left. Occurrence on the right side solely is very rare and this should be investigated for right renal tumors. Varicocele may be bilateral in 10% of the patients.
In general, varicocele does not cause any physical complaints until it becomes serious. Sometimes, patients with advanced varicocele may have testicle pain, shrinking, fullness sense. Varicocele may cause a blunt pain sensed on groins and retraction feeling on the testicle. Pain increases if the individual stands for a long time, lying decreases the pain.
However, varicocele causes INFERTILITY without any physical disorder in some men.
Approximately 40 to 50% of men with infertility complaint have varicocele. In these enlarged varicosed veins, the blood should be carried into the heart with a certain rate. However, when valves within these veins are deformed, blood moves back (into testicles) especially during cases where intraabdominal pressure increase (coughing and straining i.e.).
Varicocele may be detected by examination of testicles and scrotal color doppler ultrasonographic examination. Dilated and tortuous veins may be palpated during the examination.
Varicocele is classified from grade I to grade IV.
- In Grade I, vessels are clarified by straining,
- In grade II, vessels have an intermediate thickness,
In grade III, vessels are advanced thickened,
- In grade IV, vessels are dilated much, curves have made big balls and testicles may become smaller due to disrupted circulation.
When the patient is lied down, pampiniform plexus is discharged and venous patches disappear. If it is not disappeared, a varicocele secondary to a renal tumor, retroperitoneal or intreparitoneal tumor and further tests such as IVP, abdominal ultrasonography and computed tomography should be planned.
SCROTAL COLOR DOPPLER ULTRASONOGRAPHY
With the examination performed by ultrasonography, testicle structure and size may be detected and intravenous blood flow may be examined.
SPERMIOGRAM test must ne ordered for every patient whose varicocele was detected (if the patient is not before puberty) to examine a possible testicle damage. Details of spermiogram have been presented in infertility page. If the patient is in childhood, testicle sizes should be followed closely by volume measurement devices.
About more than half of the patients with varicocele have decreased sperm count and mobility, and their sperm nature is disrupted. (sperm count 20 million /ml, mobility 50%, morphology below 50% according to WHO)
Varicocele is a cause of male infertility which may be recovered best by a treatment. Treatment is very successful. The only treatment of varicocele is cancellation of operation of varicosed veins. The most common method for this is SURGERY. Another method is EMBOLIZATION. Surgical treatment is recommended for the men with varicocele who have infertility complaint and/or severe pain complaint or whose testicle has become smaller significantly than the other. For varicoceles during the childhood, follow-up of testicle development or surgery for advanced varicoceles are recommended. There are open surgery and laparoscopic techniques.
The principle is same in all methods and varicosed veins with disrupted function (internal spermatic vein, external spermatic vein, cremasteric vein) is ligated and sperm channels and testicle arteries and lymph vessels should be protected.
Open surgical techniques may be as normal open surgery or microscopic techniques. Varicocelectomy may be performed easily by local anesthesia that will be applied onto the inguinal area or spinal anesthesia from the back or general anesthesia. The surgery is performed with a small cut from the inguinal area. Varicosed veins are ligated and cut. It is a simple surgery and does not require hospitalization in general, however it should be performed carefully and with an optical loop. The surgery lasts about 20 to 30 minutes. During the procedure, it should be cared that other formations related with testicle should not be damaged.
If varicocele surgery is not performed carefully and lymphatic vessels are ligated, hydrocele (fluid accumulation around testes), if the artery is ligated, testicle atrophy may be observed. Experience of the urologist is important for this procedure.
As 90 days are required for a sperm cell between initiation of the production and storing after maturation roughly, disorders of sperm cells start to recover at 3 months after varicocelectomy. Therefore, first sperm analysis should be performed at 6th month after the surgery. Recovery n sperm production is seen 70% of the patients operated. The studies conducted have indicated that those who have undergone the varicocelectomy surgery have babies.
In this procedure, an obstructing coal or similar agents are placed on the top point of the varicosed veins via a catheter just like angiography and operation of these veins are cancelled.