Varicoceles

What is a varicocele?

A varicocele is a dilatation of veins/ varicose veins above the testicle and around the testicle. This condition is entirely benign.

What are the typical symptoms and how are varicoceles diagnosed?

Varicoceles can often be asymptomatic - meaning that there are no bothersome symptoms at all. In some men, varicoceles can bring on testicular pain. This pain is typically described as a dragging, dull-ache, that comes on at the end of the day or after long periods of standing. Men might also complain of "swelling" of the scrotum associated with the pain.

In some men, varicoceles can also be associated with sub-fertility, and presenting in men who are having difficulties in conceiving. Not all men with varicoceles will have problems with conception.

Varicoceles can be diagnosed by a clinical examination by a urologist and/ or ultrasound scan of the scrotum/ testicles.

Do varicoceles need to be treated?

Varicoceles are entirely benign. Treatment will depend on symptoms that men might have. If a man has significantly bothersome symptoms that impede daily life activities and impose on quality of life, then it is definitely worth seeking advice from a urologists to see if treatment might be appropriate. It should be borne in mind that not all testicular pain is related to the varicocele, and that treating a varicocele might not always improve or cure the pain. In a very minority of patients, treatment of a varicocele might make the pain worse, which is why an opinion from an experienced urologist is this area is of paramount importance.

What are the treatments for varicoceles?

The first option to be considered in any decision making process - is the option to do nothing. As part of the decision making process, one needs to weigh up the potential benefits versus the risks associated with the treatment. In the first instance, for any benign testicular pain, treating oneself with simple analgesia in the form of paracetamol and ibuprofen might be sufficient for acute exacerbations of pain. If this happens very infrequently, then the patient might decide that invasive treatment for varicocele is not necessary or justified.

However, frequent bouts of pain, persistent pain, or debilitating pain might necessitate surgical/ invasive treatment.

There are multiple options to treat the pain, but current guidelines recommend either microsurgical varicocele ligation or varicocele embolisation.

What is varicocele embolisation?

This treatment is typically provided by an interventional radiologist (imaging and x-ray specialist). It is usually done under local anaesthetic (so the patient is awake), and the patient can go home after the procedure is done the same day. A needle and guidewire (usually in the groin or neck) is used to thread coils into position in the testicular vein with x-ray guidance. Coils are left in the testicular vein to prevent the "reflux" or back-flow of blood down the testicular vein into the scrotum.

What can I expect after varicocele embolisation?

After the procedure you will be given advice by the radiology team about after-care. there may be some swelling/ bruising of the area in the groin used to access the veins with the needle and guidewire. Some patients may experience an ache in the lower back or testicle after the procedure which is expected. The veins above the testicle may become more swollen and tender for a few days after the procedure, this may resolve gradually over time although the veins may not completely disappear.

How successful is varicocele embolisation?

Varicocele embolisation has a success rate of about 80% in treating varicoceles. Overall it is a minimally invasive treatment which is generally safe, and doesn't require an general anaesthetic (where the patient is put to sleep).

What are the main risks entailed with varicocele embolisation?

Risks associated with this procedure include: bruising/ swelling/ pain/ infection at the site of access (i.e. site were the radiologists punctures the skin to get into the vein); Back pain for a few days after the procedure; the risk of failure of procedure to resolve symptoms; risk of recurrence; extremely rarely - migration of the coil resulting in blockage of an unintended vein.

What is varicocele microsurgical ligation?

This procedure is commonly done through an incision in the groin, and a microscope is used to precisely identify and ligate (cut and tie-off) the varicocele veins. Using the microscope reduces some of risks associated with this procedure because it enables the surgeon to avoid damage to other structures lying next to the varicocele veins, namely arteries, lymphatics and nerves. The procedure is usually done under general anaesthetic (patient is put to sleep). The patient usually goes home the same day after surgery. The sutures used to close the wound are usually absorbable (which means that the suture disappears or comes off on it's own).

What can I expect after varicocele microsurgical ligation?

Some patients may experience an ache or pain in the testicle for a few weeks after the procedure (this is expected) and we would generally advise patients to take it easy for the first 2 weeks while the wound heals. Patients may still be able to feel the veins in the scrotum as the veins are just tied off i.e. the veins are not removed completely. Less commonly a vein may thrombose (a clot forms in the vein) which the patient may feel like a firm "cord"in the scrotum. This is nothing to worry about, and will settle with time and the use of anti-inflammatory pain medications such as ibuprofen.

How successful is varicocele microsurgical ligation?

Overall the success rate is around 80-90%

What are the main risks entailed with varicocele microsurgical ligation?

As with any surgery, there are risks associated with having a General Anaesthetic (GA) - in a fit and healthy individual the risks are very low indeed. Specific risks with this procedure include: bruising/ swelling/ pain of the wound and scrotum; the external appearance of the varicocele may not change much although the symptoms may improve; a risk of testicular atrophy (or shrinkage/ loss of the testicle on the same side, this may occur if the blood supply to the testicle is interrupted), the risk with this is about 5%; Hydrocele formation (the risk again is low and reduced due to the use of the microscope); risk of failure of procedure to resolve symptoms; risk of recurrence of the varicocele; pain or discomfort due to phlebitis in the blocked veins, this may last few weeks.

It should be noted that the veins above the testicle may not be completely disappear following the surgery. They can become more prominent and uncomfortable as they are blocked and may become inflamed (phlebitis) soon after the surgery. Sometimes a clot can form in the vein ("thrombosed"). This can be managed with paracetamol and/ or ibuprofen initially. They become less obvious with time but they may not disappear completely.

Which procedure should I choose? Which one is better?

Overall it is believed that the microsurgical ligation of varicoceles has a slightly higher rate of successful treatment/ lower recurrence rate versus embolisation, although some studies have shown no significant difference. This is because it is believed to target multiple venous channels rather than just the testicular vein which is embolised. On some occasions, one procedure may be preferred over another and discussing the options with a urologist is crucial to tailor the treatments options to an individual. For example, some patients may be needle phobic or very anxious, meaning they would not be able to tolerate the embolisation procedure. In some patients, embolisation may not be possible due to their venous anatomy. Some patients might have other medical conditions making general anaesthetic less safe, in which case embolisation may be the better option. The choice in treatment should be discussed with an experienced urologist who can tailor advice to the each individual patient's circumstance.

Can Ms Anastasiadis advice me on varicoceles?

Ms Anastasiadis has a specialist interest in testicular pain, varicoceles and male fertility problems. She sees multiple patients every week, including on the NHS, who complain of testicular pain and with varicoceles. Her NHS service offers access to both embolisation and microsurgical ligation, and as such, has built up sub-specialist experience in evaluating and advising men about their varicoceles and treatment options.

Varicoceles, Ms Anastasiadis