Varicocele in Men: Symptoms, Diagnosis, and Modern Treatment Methods

What is varicocele?

Varicocele is an enlargement of the spermatic cord veins located around the testicle, forming the so-called pampiniform plexus. This condition is similar to varicose veins in the legs, but manifests in the scrotum. Varicocele is one of the most common urological diseases in men, especially in adolescence and young adulthood. Estimates suggest it occurs in approximately 15-20% of the male population, and among infertile men, this figure can reach 35-40%. Varicocele most commonly develops on the left side due to the anatomical features of venous outflow. Right-sided or bilateral varicocele is less common.

Causes of varicocele development

The main cause of varicocele development is the malfunctioning of venous valves in the spermatic cord veins. Normally, these valves prevent the backflow of blood, ensuring its movement toward the heart. When they fail, blood begins to stagnate in the veins, leading to their enlargement and the formation of varicose nodes.

Anatomical factors play a key role, especially for left-sided varicocele. The left testicular vein empties into the left renal vein at a right angle, which creates conditions for increased pressure and difficult blood outflow. The right testicular vein empties directly into the inferior vena cava, making it less susceptible to such problems.

Factors contributing to the development of varicocele also include:

• Genetic predisposition to venous wall weakness.
• Increased intra-abdominal pressure (e.g., from chronic constipation, heavy physical exertion).
• Prolonged standing.
• In rare cases, secondary varicocele can be caused by compression of the testicular vein by a tumor or other masses in the abdominal cavity or retroperitoneal space.

Symptoms and signs of varicocele

Varicocele is often asymptomatic and discovered incidentally during a medical examination or screening for other problems, such as infertility. However, some men may experience the following symptoms:

• Pain sensations: A dull, pulling ache or a feeling of heaviness in the scrotum, especially after physical exertion, prolonged standing, or at the end of the day. Pain may worsen in hot weather. The intensity of pain varies from mild discomfort to pronounced.
• Visual changes: Enlarged veins may be visible under the skin of the scrotum, especially in a standing position. They may feel like a "bag of worms" upon palpation. In some cases, the testicle on the affected side may look or feel smaller (testicular atrophy).
• Infertility: This is one of the most serious consequences of varicocele. Elevated temperature in the scrotum due to blood stasis, as well as impaired blood supply to the testicle, can negatively affect spermatogenesis, leading to a decrease in sperm count and motility, as well as an increase in the number of abnormal forms.
• Cosmetic defect: Some men may experience discomfort due to the appearance of the scrotum.

It is important to note that the severity of varicocele (grade I, II, III) does not always correlate with the intensity of symptoms or the degree of fertility impairment.

Diagnosis of varicocele

Diagnosing varicocele is usually straightforward and includes several stages:

1. Physical examination: The doctor inspects and palpates the scrotum in standing and lying positions, as well as during straining (Valsalva maneuver). This allows assessment of the degree of venous dilation and changes with body position.
2. Scrotal ultrasound with Dopplerography: This is the primary instrumental diagnostic method. Ultrasound allows accurate determination of the presence and degree of spermatic cord vein dilation, measurement of their diameter, assessment of blood flow, and detection of reflux (backward blood flow) during the Valsalva maneuver. Dopplerography also helps rule out other causes of scrotal pain.
3. Spermogram: If a man seeks help for infertility, a semen analysis is mandatory to evaluate sperm quality. Spermogram results may show oligozoospermia (low sperm count), asthenozoospermia (reduced motility), or teratozoospermia (increased abnormal forms).
4. Hormonal studies: In some cases, blood tests for hormone levels (e.g., testosterone, FSH, LH) may be prescribed to assess testicular function.

Methods of treatment for varicocele

Treatment for varicocele is generally surgical. Conservative methods (wearing supportive underwear, venotonics) do not eliminate the cause of the disease and can only temporarily reduce symptoms.

Indications for surgical treatment include:

• Presence of pain or discomfort in the scrotum.
• Impaired spermatogenesis confirmed by a spermogram in men planning fatherhood.
• Growth retardation or testicular atrophy on the side of the varicocele in adolescents.
• Cosmetic defect.

There are several surgical approaches:

1. Open surgeries (Ivanissevich, Palomo): Classical methods in which enlarged veins are ligated and transected through a small incision in the inguinal region or retroperitoneal space. The Palomo procedure involves ligating the testicular artery along with the veins, which reduces the recurrence risk but may pose potential risks to the blood supply of the testicle.
2. Microsurgical subinguinal or inguinal varicocelectomy (Marmar procedure): Considered the "gold standard" in varicocele treatment. Performed through a very small incision in the inguinal area using an operating microscope. This allows the surgeon to carefully identify and ligate only the dilated veins while preserving arteries, lymphatic vessels, and the vas deferens. The method is characterized by a low risk of complications and recurrences.
3. Laparoscopic varicocelectomy: A minimally invasive method in which instruments and a camera are inserted through several small punctures in the abdominal wall. The surgeon ligates the veins in the retroperitoneal space. This method provides a good cosmetic effect and quick recovery, but requires general anesthesia and carries risks associated with abdominal access.
4. Endovascular embolization: A minimally invasive procedure in which a catheter is inserted through a puncture in a vein (usually in the thigh) and guided under X-ray control to the testicular vein. Special substances (sclerosants) or coils are then introduced into the vein to block blood flow and cause its obliteration. The advantages are the absence of incisions and rapid rehabilitation.

The choice of treatment method depends on the grade of varicocele, the patient's age, the presence of symptoms, spermogram results, and the surgeon's preferences.

Prevention and living with varicocele

There are no specific preventive measures for varicocele, as its development is often associated with anatomical features and genetic predisposition. However, maintaining a healthy lifestyle, avoiding excessive physical exertion involving straining, and preventing chronic constipation can indirectly reduce the risk or slow progression.

Men diagnosed with varicocele, especially if it is asymptomatic and does not affect fertility, are recommended to undergo regular monitoring by a urologist. When planning a family or if symptoms appear, it is necessary to consult a doctor in a timely manner to assess the condition and determine treatment tactics. Early detection and adequate treatment of varicocele, especially in adolescents, can prevent the development of testicular atrophy and preserve reproductive function.

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The information provided in this article is for informational purposes only and cannot replace professional medical advice. Always consult a qualified specialist for diagnosis and treatment.