Varicocele: how to recognize and treat it

It is one of the most frequent pathologies of the male genital apparatus. Despite being asymptomatic, it can impair fertility.

Infertility is the last of a teenager’s thoughts. Yet treating at this age a very common testicular disease such as varicocele can avert this risk and ensure the future possibility of procreation.

«Varicocele is in fact the main cause of male infertility,” confirms Vincenzo Mirone, andrologist and head of communication at the Italian Society of Urology. “We consider that today about 240,000 in Italy aspire to become parents, that 20 percent – that is, 48,000 couples – have infertility problems and 24,000 for male causes, in 80 percent of cases they are men suffering from varicocele”.

What is varicocele

Varicocele is a varicose disease, as the name implies, characterized by a dilation of the veins that affects the scrotum, the sac in which the testicles are enclosed, suspended and connected to the belly by the spermatic cord that runs through the scrotum and the inguinal canal. The spermatic cord is composed of veins, arteries, nerves and sperm transport pathways from the testicles to the penis.

Although varicocele can sometimes cause localized swelling or pain or a sense of heaviness in the scrotal, it is generally a condition that does not cause any symptoms. However, it can have complications: it can cause (imperceptible) shrinkage of the testicles and, over time, a reduction in the number and quality of sperm and can also interfere with testosterone production.

The testicles are supplied with blood by the testicular artery that is located in the pelvis, the lowest part of the abdomen, and that arrives in the scrotal sac through the scrotal canal; Then the blood returns to the heart passing through some small veins in the scrotum (pampiniform plexus), from which the testicular vein (or internal spermatic vein) originates, which on the right flows into the inferior vena cava and on the left in the left renal vein.

Mirone explains: “Due to a congenital weakness of the venous walls associated with an incontinence of the valves that regulate blood flow, the spermatic vein that goes from the kidney to the testicle (therefore called renal vein), or the small veins in the testicle can dilate and widen because the venous tissue has insufficient tightness. This causes the blood to stagnate and that the temperature of the scrotum, which is normally 34.2 ° C (ie 2.3 ° C lower than that of the body) increases reaching the body, 36.5 ° C. Sperm production (spermatogenesis) is very sensitive to temperature. The increased heat causes it to be lower than normal and to decrease their motility, compromising fertility“.

When it manifests itself

The disease occurs with puberty and usually affects between the ages of 15 and 25. In 85 percent of cases it is located in the left testicle, in 11 percent it is bilateral and only in 4 percent of cases it is in the right testicle.

According to a study published in the Italian Archive of Urology and Andrology, conducted on 5,000 children in six different Italian cities, 18 percent of eighteen-year-olds suffer from varicocele. “Unfortunately, with the abolition of the military visit, in 2005, a fundamental moment of screening has disappeared, right at the entrance of adulthood, which in the past allowed to solve disorders: varicocele, but also cryptorchidism, that is, the testicles not descended into the scrotum, and short frenulum, which today remain completely undiagnosed”.

These are very simple problems to be identified early, but unknown because the andrologist is equally unknown to males. Only 10-15 percent of young people know that there is a male health specialist, and very few go. Unlike their peers, who much more often are accompanied by mothers to the gynecologist shortly after puberty.

Eight out of ten Italians have never visited a urologist or andrologist, and if more than 40 percent of girls under twenty have been to the gynecologist, less than 5 percent have been to the corresponding male specialist.

Instead, it would be essential that the boys also make a first check-up visit to an andrologist, also for a comparison on the issues of body change and sexuality, as well as to verify the absence of disorders to the urogenital organs or to identify a cure.

«From adolescence onwards, men should also learn to avoid lifestyles harmful to sexual and reproductive life (unbalanced diet, overweight, smoking, alcohol abuse, use of doping substances) and to perform self-examination to keep the health of the genital organs under control. Varicocele – as well as sexually transmitted diseases, prostatitis, urogenital tumors – is in fact on the rise.

Symptoms

Varicocele is asymptomatic: the pain is only sometimes there and is due to excessive blood pressure inside the dilated veins, when holding the standing position for a long time, during sports or lifting weights.

Observing one’s own family, however, could give some indication of the risk of suffering from it: “It is a genetic-familial disease, for which it is likely the presence of fathers, mothers, grandparents, uncles prone to varicosity and suffering from disease of the venous elastic tissue in the form of hernias, varicose veins, pulmonary emphysema and, of course, varicocele“.

Although rarer than the male one, there is also the female pelvic varicocele, caused by a congenital incontinence of the ovarian veins that causes chronic pain.

In the male, if the varicocele is not intercepted as soon as possible, scrotal hyperthermia leads to the volumetric reduction of the testicle which, being smaller, produces fewer spermatozoa: «If varicocele is not intercepted, in fact, there is first of all hypotrophy of the testicle: this scrotal hyperthermia leads to the volumetric reduction of the testicle which becomes smaller, hypotrophic and therefore produces fewer spermatozoa and causes a reduction in their mobility, because heat damages their DNA.”

A discovery that, more and more often, is made when the man, perhaps over thirty, turns with his partner to a center for medically assisted procreation. And, according to studies, about 30 percent of male patients over 25 years of age have a progressive increase in semen alterations.

The number of sperm, in recent decades, has almost halved: according to a survey a few years ago between 1940 and the 90s the average concentration – for multiple reasons, including stress and incorrect lifestyles – would have collapsed from 113 to 66 million.

Diagnosis

Varicocele is identified first of all with the visit: the family doctor can also notice it, but only an andrologist or a urologist can evaluate a deepening of the causes and the entity, through ad hoc examinations.

The andrologist or urologist assesses the morphological and structural characteristics of the testicles and to confirm the diagnosis prescribes an ultrasound with echocolordoppler of the spermatic vessels, a harmless and painless examination that assesses the vascularization of the testicles. Then follows a spermiogram, i.e. the microscopic examination of the seminal fluid, which consists:

• in the evaluation of liquefaction after ejaculation and viscosity
• in cell phone counting
• in the observation of the shape and motility of spermatozoa.

The concentration of sperm must be at least 15 million per milliliter and motility of 30 percent or higher, while normally only 5 percent of ejaculated sperm are not perfectly conformed.

With particular regard to motility, with the spermiogram it is possible to evaluate which of the following classes the spermatozoa examined belong to:

In case of a positive outcome, with constant blood reflux around the testicle, the specialist assesses the need for an intervention that eliminates the venous varicose veins that prevents the proper functioning of the testicle and that can therefore be decisive in restoring fertility.

Therapy

“The treatment is very simple,” Mirone reassures. “It is a minimally invasive surgery, under general anesthesia, which consists of a tiny incision of 2-3 cm just above the navel and the identification of the affected testicular vein, which is bound. Within about 12 months the seminal pathway improves, as well as the chances of achieving a pregnancy.”

In some cases, less frequent, percutaneous scleroembolization through catheters is also possible, performed under local anesthesia by an interventional radiologist who occludes the dilated veins with ad hoc substances.

One of the most frequent complications is recurrence, up to 35 percent: the surgeon’s experience is very important, so it is important to rely on a specialized hospital center, even if the intervention is not complex.

Not only varicocele

There are many pathologies that affect the male urogenital system of Italians:

The Italian Society of Urology, in collaboration and with the patronage of the Ministry of Health, has promoted the “Alpha Prevention” campaign to spread the message that prevention is fundamental in all phases of human life, from adolescence to old age. And as is already the case for women, who in the gynecologist have a constant reference of their health, men can also count on an ally: the trusted urologist.