A varicocele is a collection of varicose veins around the testicle. Varicose veins can be seen in other parts of the body. If you have seen someone with large veins on their leg that bulge when they stand up and disappear when they lie down, you have seen varicose veins. Varicocele is the word used to describe varicose veins in the scrotal sac around the testicle. A varicocele can be important because it can be a cause of future infertility. We understand very little about varicoceles other than what we can see on a physical exam.
Varicoceles are very common in adolescent and teenage boys and occur in approximately one of every seven or eight boys. We don’t know why a varicocele occurs in one boy and not another. We’re not even sure how they occur or exactly how they lead to infertility. The arteries and veins work differently. The heart pumps blood under pressure to the rest of the body through the arteries. There isn’t a similar pump to get the blood back to the heart. For this reason there are valves in the veins that keep the blood from going backwards when you stand up. If these valves weren’t present, your blood would run back to your feet and you would pass out. We believe that varicoceles occur because the valves in the veins that carry blood back to the heart from the testicle are not functioning properly. Because of this, when a boy with a varicocele stands up, the blood rushes backwards to the scrotum and engorges the veins around the testicle. Most varicoceles occur only on the left side, though some occur on both sides.
The only significant problem that a varicocele may cause is infertility – the inability to father children. Approximately two or three men out of ten with a varicocele will be infertile at a time when they want to have children. We are not sure how the varicocele causes the infertility. What we do know is that the affect on fertility appears to worsen with time. However, in most men the affect may occur so late in life (e.g., 60 or 70 years old) that they don’t even know it has happened or are not concerned with fertility.
Varicoceles can be corrected by a relatively simple surgical procedure. The only absolute reason to correct a varicocele is if a man is already infertile. Since the harmful effect of a varicocele seems to increase with time, it might be possible to prevent infertility if the varicocele were treated early, before infertility occurred. The challenge we have is that we cannot identify which teenager with a varicocele is going to be infertile as an adult. Because so many boys have varicoceles, we would be operating on seven or eight boys out of ten unnecessarily, in order to prevent infertility in the other two boys. We’re not even absolutely certain that early treatment will prevent future infertility.
We do know that a varicocele can prevent growth of the involved testis. We also know that if the varicocele is successfully corrected, the testis will catch up in size to the other testicle in six of ten boys. This would seem to be a good reason to fix a varicocele in a boy with a small testis but, again, we’re not certain if the presence of a small testis will cause infertility or if making it grow larger will prevent future infertility. Pediatric urologists are not in agreement about whether surgery should be recommended in this particular group of boys. Many physicians would recommend treatment if a varicocele is present on both sides.
Pediatric urologists follow boys with varicoceles to see how the testis is growing. This might be on an every six-month basis, or once a year. If the boy reaches full adult development (approximately 18 years of age) an analysis of the semen can be performed. If it were abnormal at that time, correction of the varicocele would be recommended. If the analysis is normal, it tells us that the boy is fine at that time, but it doesn’t tell us how he will be later in life as the affect of the varicocele progresses. It is possible to perform semen analysis on younger boys, but it can be normal for the semen to be abnormal because of the younger age. For this reason, semen analysis in younger boys is not a reliable measure of future infertility.
The object of treatment of a varicocele is to interrupt, or block the vein that has been allowing the blood to go backward when a boy stands up. This prevents the veins around the testicle from becoming enlarged any more. The most common way a varicocele is corrected is by surgical division of the blood vessel somewhere above the scrotum. This is an outpatient procedure done either by an incision in the groin or lower abdomen, or by laparoscopic surgery. In some instances parents will elect to have the varicocele treated by having a catheter placed into the main vein to the heart (the inferior vena cava). The catheter is then fed back down the “bad” vein and a solid material is injected down the vein to block it. Both of these are very effective at correcting the varicocele.