Varicoceles are abnormally dilated veins in the scrotum (pampiniform plexus), found in approximately 15% of the general male population. However, there is an increased incidence of approximately 40% in men with infertility, leading to the belief that this abnormality negatively affects male fertility. Varicoceles are more commonly found on the left-side, and are extremely rare before puberty.

What are the risks associated with varicoceles?

Although most men with varicoceles are able to father children, and have no symptoms associated with this condition, many men can have effects from these dilated veins. These include:

• Testicular pain on the effected side
• Testicular atrophy, described as decrease in growth, or loss in size of the testicle on the effected side.
• Infertility can be caused by varicoceles, and this issue is typically diagnosed upon obtaining a semen analysis demonstrating abnormalities in sperm count, shape, and/or motility.

What causes varicoceles?

Varicoceles may arise secondary to reflux of venous blood into the pampiniform plexus as a result of absent or incompetent valves within the internal spermatic vein. At this time there is no data to suggest a genetic basis for these lesions and hereditary patterns have not been identified. Retroperitoneal masses such as sarcomas, lymphomas, and renal tumors have been known to cause varicoceles by obstructing venous outflow from the testicles but varicoceles are not known to be a component of any clinically recognized syndrome.

The exact mechanism whereby varicoceles cause impaired testicular function remains poorly understood. Theories include abnormally high scrotal temperature, decreased oxygen circulation to the testicle due to venous stasis, dilution of intratesticular hormones (e.g. testosterone), imbalances of the hypothalamic-pituitary-gonadal axis responsible for signals from the brain to the testicle to produce testosterone, and reflux of renal and adrenal metabolites and waster products down the spermatic vein.

How are varicoceles diagnosed?

The diagnosis of a clinical significant varicocele is generally made on physical examination of the scrotum and its contents. The scrotum should be inspected carefully for any easily visible or palpable dilated veins. The severity of the varicoceles is graded on a scale from I-III.

• Grade I: Small, palpable only when patient strains
• Grade II: Medium, palpable at rest (without strain), but not visible.
• Grade III: Large, easily visible through the scrotal skin when standing.
• Subclinical: Vein is larger than 3 mm on ultrasound, but not palpable on exam.

Scrotal ultrasonography with color flow Doppler imaging may prove useful in equivocal cases or in patients with a body habitus that makes accurate physical examination of the scrotum impossible. However, scrotal ultrasounds are not a routine part of the evaluation of varicoceles. Any subclinical varicocele seen on ultrasound, but not palpated upon exam does not require treatment.

Which patients require treatment of varicoceles?

The majority of men with varicoceles remain fertile and asymptomatic. Therefore, treatment of all varicoceles is clearly unnecessary. Surgical correction is recommended if a varicocele is clinically detected and one, or more, of the following is true:

• Associated with abnormal semen parameters in an infertile couple
• Adolescent male with atrophy of the testicle on the same side as the varicocele
• Associated with testicular pain on the same side as the varicocele

What is the treatment for varicocele?

A variety of surgical approaches have been advocated for varicocele repair (varicocelectomy), including open surgical, laparoscopic, and percutaneous techniques. The goal of the procedure is to identify and ligate the dilated veins within the scrotum, while leaving the important surrounding structures such as the, testicular arteries, lymphatics, and vas deferens intact.

Here we provide a microsurgical subinguinal, varicocelectomy technique. This allows a minimally invasive, outpatient, approach to the repair, with minimal pain, short recovery time, and incredibly detailed visualization of the anatomy, to allow for the reliable identification and preservation of the testicular artery or arteries, cremasteric artery or arteries, and lymphatic channels.

The introduction of microsurgical technique to varicocelectomy has resulted in a substantial reduction in the incidence of postoperative hydrocele formation and testicular atrophy or azoospermia, respectively. This is because the lymphatics can be more easily identified and preserved. Furthermore, the use of magnification enhances the ability to identify and preserve the testicular artery, thus avoiding the complications of atrophy or azoospermia.

What are the risks of varicocelectomy?

The risks of performing a microsurgical varicocelectomy are fairly low, and very uncommon. As with any surgical procedure, there is always a small risk of infection or bleeding, but appropriate precautions are taken to minimize these complications. Other risks and approximate incidence with microsurgical varicocelectomy include:

• Hydrocele formation (5%-7%)
• Recurrence of varicoceles (1%-5%)
• Testicular artery ligation or injury with testicular atrophy or loss (less than 1%)

What are the goals for therapy?

Increasing evidence suggests that varicocele ligation improves semen quality and pregnancy rates, in those patients suffering from infertility with identification of this male factor. It is important to understand that pregnancy rates still vary, and depend on the reproductive health of both partners, not just the male patient. The female partner should be evaluated by a gynecologist or reproductive endocrinologist in tandem with the male partner's evaluation by his urologist.

In adolescents diagnosed with varicoceles and accompanying testicular atrophy, studies show that varicocele repair leads, not only to a halting of loss of testicular mass, but also rapid catch-up growth of the affected testicle. Additionally, as adults, patient semen parameters seem to be improved in those patients who had their varicoceles repaired during adolescence, compared to those who decided against repair.

Finally, in those men experiencing pain related to varicoceles, microscopic varicocelectomy seeks to achieve relief of that discomfort. This intervention is only recommended for the treatment of scrotal pain once all other causes of testicular pain have been ruled out, and all conservative measures for pain control have been exhausted. When varicocele truly identified to be the cause for a man's testicular pain, repair is appropriate. However there are some instances when varicocelectomy fails to relieve the discomfort entirely and patients should be made aware of this.