Varicoceles - Varicose Veins in the Testicles

Varicoceles are varicose veins that occur in the scrotum. Doctors also refer to the condition as a “varicose vein hernia.” “Varico” stands for varicose veins, and “cele” for protrusion or hernia. However, a varicocele does not involve a hernia in the strict sense; rather, the venous plexus running along the spermatic cord enlarges. Blood flows through this plexus, and in some men, this blood becomes pooled due to various causes. 

This leads to blood congestion in the venous plexus. The clinical picture is thus similar to that of varicose veins in the legs. The medical term for this venous plexus in the scrotum is plexus pampiniformis (literally: vine-like plexus).

Based on current research, doctors classify varicoceles according to how pronounced and how easily recognizable they are. In addition, they differentiate between left-sided, right-sided, and bilateral varicoceles. However, they are most commonly located on the left side (90%), less commonly on the right (7%), and very rarely on both sides (3%).

People with mild varicoceles often experience no pain or other symptoms. In such cases, the condition is often discovered incidentally. 

Advanced varicoceles, on the other hand, are recognizable as worm-like swellings that can be felt beneath the skin of the scrotum. They are particularly visible when the affected person tenses their abdominal muscles. This is due to increased pressure in the abdominal cavity caused by tensing the abdominal muscles, which impairs venous outflow and leads to a backup of blood.

Some patients also suffer from

• swelling
• a feeling of tightness, as well as
• pain in the scrotum or
• the testicles feel distended or swollen (especially when standing)

Varicoceles in children and adolescents often manifest as smaller testicles. The reason: The condition inhibits testicular growth.

Varicoceles may be a taboo topic, but they are common—about 15 percent of all men have or have had a varicocele at some point. Statistically speaking, they occur most frequently in young men during puberty, with the peak incidence occurring between the ages of 15 and 25. However, varicoceles can also occur in children.

Most patients, however, do not notice them until adulthood, as symptoms rarely occur in the early stages. This makes it all the more important to conduct further examinations if varicoceles are suspected and to arrange a referral to a urologist, if necessary, to prevent long-term damage. The most serious consequence is certainly infertility due to impaired testicular maturation.

Doctors distinguish between primary (idiopathic) varicocele and secondary (symptomatic) varicocele.
These conditions have different underlying causes. Primary varicocele is congenital and occurs more frequently in tall, slender men. 

It is often caused by a defective venous valve in the testicular vein or a weakness in the vessel wall. Impaired venous outflow due to increased vascular pressure is also a possible cause of the primary form of varicocele. 

The secondary form of the condition is not congenital but acquired. It occasionally occurs bilaterally and is caused, for example, by tumor-related blood stasis. This includes tumors of the kidney, the renal pelvis, or the ureter, among others. In rare cases, varicocele in the testicle is caused by a thrombus (blood clot) or a rupture (tear) in the veins.

Researchers and doctors suspect that varicoceles can negatively affect male fertility. Studies show that men with reduced fertility are more likely to have a varicocele than fertile men. According to estimates, 25 percent of men with reduced fertility have varicoceles. 

However, the condition does not rule out fertility by any means. There are men who are able to conceive normally even though they have a varicocele. However, anyone hoping to have children should consult a urologist (a specialist in diseases of the kidneys, urinary tract, and male reproductive organs) to discuss treatment options.

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If the varicocele is large, it is already visible and palpable from the outside. In some cases, it disappears when the patient is lying down, but it is usually easy to examine and visualize when the patient is standing. 

Smaller varicoceles, however, are not always immediately recognizable, especially in the early stages. In such cases, an ultrasound (sonography) is necessary. This allows the condition to be diagnosed; however, further tests may be required if the doctor deems them appropriate.

For example, men who wish to have children are recommended to undergo a semen analysis (spermiogram). This provides further information regarding fertility. If abnormalities are found, this may be due to a varicocele. Nevertheless, a blood test should be performed to check hormone levels—such as the sex hormone testosterone—to rule out other causes of infertility.

Treatment of varicoceles is generally possible, but not always necessary. Varicoceles often resolve on their own over time. Treatment is advisable if the patient wishes to have children or is experiencing severe symptoms such as pain. 

The treatment typically involves blocking off the dilated veins. This allows blood to flow through healthy veins located adjacent to the affected vein. Treatment is performed either through

• varicocele sclerotherapy
• occlusion (embolization), or
• surgery on the varicose vein.

To close off or sclerose the affected vein, the treating physician injects a medication into the testicular vein.

In cases of varicoceles with a secondary cause, it is necessary to eliminate the actual underlying cause. Depending on the cause, this is done—for example—through appropriate tumor therapy.

When is surgery necessary for varicoceles?

Patients with a varicocele likely prefer the less invasive sclerotherapy procedure. However, this is not possible for all patients. Therefore, a decision is made on a case-by-case basis as to which treatment is feasible and recommended. 

In the conventional surgical method, the vein is severed in the groin or on the side of the abdomen through a small incision. Additionally, laparoscopic surgery—that is, using the keyhole technique—can be performed in the testicle or abdominal cavity to sever the varicose veins in the testicle and the veins supplying them (varicocelectomy). This resolves the blood congestion, and blood flows away again through other, healthy veins.

Varicoceles are usually easily treatable. The chances of a successful outcome following medical intervention are high. In principle, the earlier treatment begins, the easier it is to resolve or occlude the blood congestion in the testicular vein. Therefore, it is advisable to see a doctor immediately if symptoms occur or a palpable mass is felt. The goal of treatment is to reduce pain and improve sperm quality. Restoring normal hormone levels is also a goal of treatment.

Varicoceles are certainly not pleasant once they start causing symptoms. Anyone experiencing pain or a feeling of pressure in the testicular area should therefore see a urologist right away. This is especially true for men who have not yet completed their family planning. With the right treatment, normal function is usually restored within a short time, so there is no need to worry about long-term damage.

What is a varicocele and how does it
develop? A varicocele is a condition in which veins in the scrotum—and thus the testicles—are affected. It is often caused by defective venous valves or anatomical abnormalities, which lead to blood pooling in the venous network.

What symptoms and discomforts are associated with varicoceles?
Many men do not notice any symptoms at first, especially with small varicoceles. With larger varicoceles, pulling pain in the testicles, swelling, a feeling of tightness, or discomfort such as pain when standing may occur.

Can a varicocele affect
fertility? A varicocele can affect fertility, as impaired blood flow and increased temperature in the scrotum can negatively impact sperm quality. Therefore, a urological evaluation—including a semen analysis—is recommended, especially for men who are having difficulty conceiving.

How is a varicocele treated
? Treatment for a varicocele depends on symptoms, severity, and the desire to have children. Possible treatments include sclerotherapy, occlusion of the affected vein, or surgical treatment, in which the dilated venous plexus is ligated so that blood can once again flow through healthy veins.