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Aug 27, 2006
Varicocele embolization
by SirGan
 A varicocele is an enlargement of the veins within the scrotum- bag of skin that holds the testicles. To understand it more easily – it could be said that a varicocele is similar to a varicose vein of the legs. It isn't so rare condition because latest researches show that up to 1 in 5 men have a varicocele. For males who are infertile, the figure is higher — about 40 percent. Although no one really think that it could be so serious- the proven fact is that varicoceles are the most common cause of low sperm production and decreased sperm quality, although not all varicoceles affect sperm production. It is also proven that they usually occur in 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. Fortunately, most varicoceles are easy to diagnose and, if they cause symptoms, can be repaired surgically. One of the latest, most effective and minimally invasive, outpatient procedure is called varicocele embolization. Normal anatomyIt could be extremely important to know some basic things about the normal anatomy and pathophysiology of this condition. The term varicocele specifically refers to dilatation and tortuosity of the pampiniform plexus. Pampiniform plexus is the network of veins that drain the testicle. What is so important about this vein plexus? Well, this plexus travels along the posterior part of the testicle with the epididymis and vas deferens, and then into the spermatic cord. There is one big difference between left and right testicle! The right testicle vein drains into the inferior vena cava, while the left testical vein drains into the left renal vein, which then drains into the inferior vena cava. This is extremely important because, with this position, there is much greater chance for left testicle to develop varicocele because of the right angle between the veins! The small vessels of the pampiniform plexus normally range from 0.
Possible causes of varicocele
Simplest putted- the cause of this type is unknown! The idiopathic varicocele occurs when the valves within the veins along the spermatic cord don't work properly. This is essentially the same process as varicose veins, which are common in the legs. So, what happens when these valves don’t work? The result is logical - backflow of blood into the pampiniform plexus and increased pressures which is ultimately leading to damage to the testicular tissue. Several researches done in the past have proven that 98% of idiopathic varicoceles occur on the left side, apparently because the left testicular vein runs vertically up to the renal vein- but- 70% of patients with varicoceles have them bilaterally.
It is important to know that a secondary varicocele is due to compression of the venous drainage of the testicle. What could be the cause of this compression? Well, a pelvic or abdominal malignancy is a definite concern when a varicocele is newly diagnosed in a patient older than 40 years of age. Patient should also know something about the famous non-malignant cause of a secondary varicocele is the so-called "nut-cracker SMA" (superior mesenteric artery). This represents a condition in which the superior mesenteric artery compresses the left renal vein, causing increased pressures there to be transmitted retrograde into the left pampiniform plexus.
The best candidates for varicoceleAlthough there are no certain criteria for developing this condition and although they don't happen to every male- the fact is that varicoceles are fairly common. Age is only risk factor for developing this condition! Experts are saying that they appear in about 15% of guys between 15 and 25 years old, and they mostly occur during puberty. How come? Well, it is all because during puberty, the testicles grow rapidly and need more blood delivered to them. So, logically- if the valves in the veins in the scrotum aren't functioning well, the veins can't transport this extra blood from the testicles. This leads to the creating a varicocele.
Although it's less common, they can sometimes occur on both sides.
Signs and symptoms of varicoceleBig diagnostic problem is that varicoceles usually develop slowly and may not have any symptoms. Like it was been told - varicocele are most frequently diagnosed when a patient is 15-25 years of age, and rarely develop after the age of 40. They occur in 15-20% of all males, and in 40% of infertile males. However, if there are symptoms, they tend to occur during hot weather, after heavy exercise, or when a guy has been standing or sitting for a long time. Signs include:
Diagnosis of varicocele
In most cases-doctor will conduct a physical exam, which may reveal a twisted, non-tender mass above patient’s testicle. Some people have described the mass as feeling like a bag of worms. If it's large enough, doctor will be able to feel it while the patient is standing up. In other cases- doctor may ask a patient to take a deep breath and hold it while he bears down. This is called the Valsalva maneuver. This helps your doctor detect abnormal enlargement of the veins.
Everyone should know that, if the physical exam is inconclusive, doctor may order a scrotal ultrasound. This test, which uses high-frequency sound waves to create precise images of structures inside body, may be used to ensure there isn't another reason for patient’s symptoms.
Complications if left untreatedA varicocele may cause:
It is important to know that the bulk of the testicle is made up of sperm-producing tubules. So, when damaged, the testicle shrinks and softens.
It's not clear how varicoceles affect fertility but some experts believe the testicular veins cool blood in the testicular artery, helping to maintain the proper temperature for optimal sperm production.
Treatment of varicoceleOpen surgeryIt is important to know that open surgery is the most common form of treatment and it usually is done on an outpatient basis. General or local anesthetic is being used. There are several approaches to the vein:
What's strange- recovery after surgical repair usually proceeds rapidly and, in most cases- patient can return to normal activities that aren't strenuous after two days. Logically there will be some pain but good thing is that pain resulting from this surgery usually is mild. Doctor should advise a patient to take over-the-counter (OTC) painkillers, such as acetaminophen (Tylenol, others) or ibuprofen (Motrin, Advil, others) to relieve discomfort. Your doctor may advise you not to have sexual intercourse for one week.
Laparoscopic surgeryIt is important to point out that, with this approach, the surgeon makes a small incision in the abdomen and passes a tiny instrument through the incision to see and to repair the varicocele.
Varicocele embolizationEvery patient should know that varicocele embolization is non-surgical solution which has been successful at eliminating varicoceles for thousands of men, and can have you back to your active lifestyle in only a few days. Many men choose this non-surgical alternative because it does not involve general anesthesia, incisions in the scrotum, or sutures.
The procedure
A radiologist inserts a tube into a vein in patient’s groin or neck through which instruments can be passed. The mechanism isn't complicate- viewing enlarged veins on a monitor, the doctor releases balloons to create a blockage in the testicular veins, which interrupts the blood flow and repairs the varicocele. This procedure uses sedation and may take several hours. Again, because of presenting greater risks than open surgery and offering little advantage, this procedure isn't widely used.
Advantages of this procedure:
Cost of this procedure
Although, it isn't cheep- the cost is generally comparable to varicocele surgery. However, the cost varies depending on geographic area and local insurance company policies.
Possible complications
Some of the most common complications are:
Embolization and semen analysis
Many studies have shown that varicocele repair can improve semen analysis significantly, but there is no guarantee. It is proven that pregnancy rates in infertile couples improve after varicocele repair by about 30-50%.
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