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The male reproductive tract is responsible for the production, maturation of sperm, and delivery of sperm. This tract is a complex and highly integrated entity. Sperm are produced in the testicles and then are transported through the genital duct system to the penis and out of the urethra during ejaculation. Each component of the reproductive tract is highly specialized. Abnormalities within the male reproductive tract may appear as scrotal masses. Masses may be of little significance or may represent life-threatening illnesses. It is necessary to follow a set course of action to determine the nature of the masses and the most appropriate treatment option. For example, testicular cancer is a source of great concern and uniformly requires prompt intervention. Other masses, such as varicoceles, can cause pain or impair reproductive function. Thus, it is important for a patient to seek prompt medical attention when he identifies a scrotal mass or abnormality while performing a testicular self examination. The following information will assist you when talking to a urologist about varicoceles.
What are varicoceles?
The spermatic cord is the structure that provides the blood supply to the testicle and contains the vas deferens which transports sperm from the testicle to the penis and urethra. The spermatic cord passes through the inguinal canal and continues into the scrotum. The pampiniform plexus is a group of interconnected veins, which drain the blood from the testicles and lies within the spermatic cord. The pampiniform plexus is believed to have an important functional role in maintaining testicular temperature in the appropriate range for sperm production. The pampiniform plexus cools blood in the testicular artery before it enters the testicles, helping to maintain an ideal testicular temperature, essential for optimal sperm production. Varicoceles are abnormal enlargements (dilations) of the pampiniform plexus of veins within the scrotum. They are similar to varicose veins of the leg, and often form during puberty. They can become larger and thus more noticeable with time. Left-sided varicoceles are more common than right-sided varicoceles, likely due to anatomical differences between the two sides. What can cause varicoceles?
Several causes of varicoceles have been suggested. Incompetent or absent valves within the gonadal or spermatic veins may lead to pooling of blood and the abnormal enlargement in the pampiniform plexus of veins. Additionally, the angle at which the gonadal vein enters the renal (kidney) vein may produce relatively high pressure within this venous system, leading to the swelling (dilation) of the pampiniform plexus. This explains why varicoceles are more common on the left side since the gonadal vein on the left side enters the renal vein. The right gonadal vein is not as long and does not join with the right venal vein. Rarely, enlarged lymph nodes or other abnormal masses in the retroperitoneum (the space behind the abdominal cavity) will block the gonadal veins, leading to increased pampiniform venous pressure and varicocele formation. This mechanism is only of concern when one develops a new varicocele. How common are varicoceles?
Varicoceles are present in an estimated 15 percent of all men, whereas approximately 40 percent of men undergoing evaluation for infertility are diagnosed with this condition. No racial or ethnic groups are known to be at higher risk for development of a varicocele. What are the symptoms of varicoceles?
Most men diagnosed with a varicocele have no symptoms, but varicoceles are important for several reasons. Varicoceles are thought to cause infertility and testicular atrophy (shrinkage). Approximately 40 percent of cases of primary male infertility and 80 percent of cases of secondary male infertility are believed to be due to varicoceles. Varicoceles rarely cause pain. When pain is present, it can vary from a dull, heavy discomfort to a sharp pain. The associated symptoms may increase with sitting, standing or physical exertion - particularly if any one of these activities occurs over long periods of time. Symptoms often progress over the course of the day, and they are typically relieved when the patient lies on his back, allowing improved drainage of the veins of the pampiniform plexus. How are varicoceles diagnosed?
Large varicoceles can be discovered through self-examination. They may look or feel like a mass in the scrotum, and they have been described as having a "bag of worms" both because of their appearance and the way they feel. Asymptomatic varicoceles are often diagnosed on physical examination at the time of routine medical evaluation. Physicians typically diagnose varicoceles with the patient in the standing position. The patient may be asked to take in a deep breath, hold it, and bear down while the physician feels the scrotum above the testicle. This technique, known as the Valsalva maneuver, assists the physician in detecting abnormal enlargement or increased fullness of the pampiniform plexus of veins. A physician may order a scrotal ultrasound test to help make the diagnosis, particularly if the physical examination is difficult or inconclusive. Radiographic hallmarks of varicoceles on scrotal ultrasonography are veins greater than three millimeters in size with reversal of blood flow within the veins of the pampiniform plexus during the Valsalva maneuver. However, most varicoceles are diagnosed in most patients on the basis of physical examination alone. Most physicians do not believe that ultrasonography should be utilized to identify small or subclinical varicoceles since several studies have shown that "subclinical" varicoceles - those detected on the basis of ultrasound or other radiographic study alone - are usually not clinically relevant. Thus, routine radiographic screening for varicoceles in the absence of physical findings is not encouraged. What are the treatment options for varicoceles?
Treatment of varicoceles is an appropriate consideration in some patients with infertility, pain or testicular atrophy. No medical therapies are available for either treatment or prevention; however analgesic agents may alleviate associated pain when present. There are two main approaches to the treatment of a varicocele: Surgical Repair: This approach involves a variety of specific techniques, but all involve ligation (obstructing) the spermatic or gonadal veins thus interrupting blood flow in the vessels of the pampiniform plexus. The surgical approaches include open surgical repairs performed through a single incision with or without the use of optical magnification (e.g., magnifying glasses or loupes or an operating microscope). Laparoscopic varicocele repair which utilizes telescopes passed through the abdominal wall are not generally used since they are thought by most to have greater potential for serious complications than standard surgical techniques without significant advantage. The open procedures are performed under a variety of anesthetics, from local to general anesthesia, whereas the laparoscopic approach is uniformly performed under a general anesthetic agent. With the advent of smaller incisions, which avoid muscle transection, the open procedures are becoming closer to the laparoscopic techniques in both speed of recovery and postoperative pain. Complications resulting from either open or laparoscopic approaches are rare, but include varicocele persistence/recurrence, hydrocele formation and injury to the testicular artery. Percutaneous Embolization: This procedure is performed by radiologists using a special tube that is inserted into a vein in either the groin or neck. After radiographic visualization of the enlarged veins of the pampiniform plexus, coils or balloons are released to create an obstruction (blockage) in the veins. This obstruction then typically leads to interruption of blood flow within the pampiniform plexus vessels and disappearance of the varicocele. Percutaneous embolization is typically performed with intravenous sedation anesthesia and usually takes several hours to complete. Complications may include varicocele persistence/recurrence, coil migration and complications at the venous access site. This has not been widely employed in most centers. What can be expected after treatment?
Recovery time after surgical repair is usually rapid. Pain is usually mild, and patients are asked to avoid strenuous activity for 10 to 14 days. Office work can typically be done one to two days after surgery. A follow-up visit with the urologist is scheduled. A follow-up semen analysis is obtained three to four months later if the procedure was performed to treat associated infertility. Open procedures performed with optical magnification have a low recurrence rate of approximately one percent. Recovery time after embolization is also relatively short. Again, pain is typically mild, and patients are asked to avoid strenuous physical activity for seven to 10 days after the procedure. Patients may return to office work one to two days postoperatively. The recurrence rate with embolization is generally thought to be higher than that achievable with optical magnification. Nevertheless, there are circumstances when embolization may be preferable. The impact of varicocele correction on fertility is not entirely clear. Some studies demonstrate improvement in fertility after varicocele repair, while other studies fail to document this change. Semen quality is improved in approximately 60 percent of infertile men undergoing correction of a varicocele, and this treatment should be considered in the context of other available treatment options as couples pursue therapy. Frequently asked questions: What will happen if I choose to observe my varicocele, rather than undergo treatment?
Failure to treat a varicocele may result in testicular atrophy and/or a decline in semen quality. This may lead to infertility. The varicocele may, over time, lead to permanent, irreversible testicular injury. I have pain with my varicocele. What can I do to help alleviate the pain?
The use of adequate scrotal support (e.g., athletic supporter, briefs style underwear, etc.) can help the pain associated with a varicocele. Lying on your back facilitates varicocele drainage and often improves episodic discomfort as well. Use of analgesic agents (e.g., acetaminophen, ibuprofen, etc.) may be of benefit in treating the pain associated with a varicocele. Additionally, many patients obtain lasting relief of symptoms with varicocele correction through the above-mentioned techniques. I am considering having my varicocele corrected for fertility reasons. How long will I have to wait to see improvement in semen parameters?
Semen analyses are typically obtained at three to four month intervals after the procedure. Improvement is often seen within six months, but may not be observed until one year postoperatively. My adolescent son was recently diagnosed with a varicocele. Should this be corrected?
Indications for correction of a varicocele in an adolescent include disparity in testicular size, with the affected side measuring greater than 2 cm3 less in volume than the unaffected side. Additionally, correction is a consideration in patients with pain. Treatment of adolescents is highly individualized, and consultation with a urologist to further discuss the appropriateness of treatment for a particular patient is highly recommended. Often patients or families will choose to repair varicoceles to minimize the potential risk for future fertility or minimize the concerns about this complication. I am interested in fertility and have no symptoms. Should I have my varicocele repaired?
Generally, asymptomatic varicoceles are not repaired. Most physicians do not believe there are health consequences of untreated asymptomatic varicoceles. Reviewed February, 2005
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abnormality:
A variation from a normal structure or function of the body.
analgesic:
A drug intended to alleviate pain.
anesthesia:
Loss of sensation in any part of the body induced by a numbing or paralyzing agent. Often used during surgery to put a person to sleep.
anesthetic:
A substance that causes lack of feeling or awareness.
artery:
Blood vessel that carries blood from the heart to various parts of the body.
atrophy:
When an organ diminishes in size.
cancer:
An abnormal growth that can invade nearby structures and spread to other parts of the body and may be a threat to life.
cutaneous:
Relating to the skin.
dilation:
The stretching or enlargement of a hollow organ or body cavity.
ejaculation:
Release of semen from the penis during sexual climax.
embolization:
The process or condition in which a blood vessel is blocked.
fertile:
Able to produce offspring.
fertility:
The ability to conceive and have children.
gene:
The basic unit capable of transmitting characteristics from one generation to the next.
general anesthesia:
Person is put to sleep with muscle relaxation and no pain sensation over the entire body.
genital duct system:
Passages within various reproductive organs.
gonad:
The organ that forms the reproductive cells.
groin:
The area where the upper thigh meets the lower abdomen.
hydrocele:
A painless swelling of the scrotum caused by collection of fluid around the testicle.
incision:
Surgical cut for entering the body to perform an operation.
infertile:
Physically incapable of conceiving children.
infertility:
The diminished ability or the inability to conceive and have offspring.
inguinal:
Located in or affecting the groin.
inguinal canal:
A space in the groin.
intravenous:
Also referred to as IV. Existing or occurring inside a vein.
intravenous sedation:
Sedatives administered directly into the veins.
ions:
Electrically charged atoms.
kidney:
One of two bean-shaped organs that filter wastes from the blood and discharge these waste products in urine. The kidneys are located near the middle of the back. The kidneys send urine to the bladder through tubes called ureters.
laparoscopic:
Using an instrument in the shape of a tube that is inserted through the abdominal wall to give an examining doctor a view of the internal organs.
liver:
A large, vital organ that secretes bile, stores and filters blood, and takes part in many metabolic functions, for example, the conversion of sugars into glycogen. The liver is reddish-brown, multilobed, and in humans is located in the upper right part of the abdominal cavity.
lymph:
Fluid containing white cells. It can transport bacteria, viruses and cancer cells.
lymph nodes:
Small rounded masses of tissue distributed along the lymphatic system most prominently in the armpit, neck and groin areas. Lymph nodes produce special cells that help fight off foreign agents invading the body. Lymph nodes also act as traps for infectious agents.
male infertility:
Diminished or absent capacity to produce offspring due to absence or deficiency of spermatozoa in the semen, or failure of formation of spermatozoa; the term does not denote complete inability to produce offspring as does sterility.
penis:
The male organ used for urination and sex.
peritoneum:
Strong, smooth, colorless membrane that lines the walls of the abdomen and covers numerous body organs including the bladder.
radiographic:
X-ray.
radiologist:
Doctor specializing in the interpretation of X-rays and other scanning techniques for the diagnosis of disorders.
renal:
Pertaining to the kidneys.
renal vein:
Short, thick vein which returns blood from the kidneys to the vena cava.
retroperitoneum:
Behind abdominal lining.
scrotal:
Relating to the scrotum, the sac of tissue that hangs below the penis and contains the testicles.
scrotum:
Also referred to as the scrotal sac. The sac of tissue that hangs below the penis and contains the testicles.
sedation:
State of calm relaxation induced in one or more body systems by administration of medical agents (sedatives).
semen:
Also known as seminal fluid or ejaculate fluid. Thick, whitish fluid produced by glands of the male reproductive system, that carries the sperm (reproductive cells) through the penis during ejaculation.
semen analysis:
A laboratory study of semen to determine the concentration, shape and motility of sperm.
sperm:
Also referred to as spermatozoa. Male germ cells (gametes or reproductive cells) that are produced by the testicles and that are capable of fertilizing the female partner's eggs. Cells resemble tadpoles if seen by the naked eye.
spermatic cord:
A cord by which a testis is suspended in the scrotum.
testicle:
Also known as testis. Either of the paired, egg-shaped glands contained in a pouch (scrotum) below the penis. They produce sperm and the male hormone testosterone.
testicular:
Relating to the testicle (testis).
testicular cancer:
Cancer of the testis.
ultrasonography:
A test in which sound waves are bounced off body tissue, and the echos are converted into a picture, for the purpose of medical examination or diagnosis, that are viewed on a monitor.
ultrasound:
Also referred to as a sonogram. A technique that bounces painless sound waves off organs to create an image of their structure to detect abnormalities.
urethra:
In males, this narrow tube carries urine from the bladder to the outside of the body and also serves as the channel through which semen is ejaculated. Extends from the bladder to the tip of the penis. In females, this short, narrow tube carries urine from the bladder to the outside of the body.
urge:
Strong desire to urinate.
urologist:
A doctor who specializes in diseases of the male and female urinary systems and the male reproductive system. Click here to learn more about urologists. Click here to view the brochure in zinio format.
(Download the free Zinio reader or the free Acrobat reader.)
varicoceles:
Dilated varicose veins in the scrotum that drain the testis and can impair the process of formation of sperm.
vas:
Also referred to as vas deferens. The cordlike structure that carries sperm from the testicle to the urethra.
vas deferens:
Also referred to as vas. The cordlike structure that carries sperm from the testicle to the urethra.
vein:
Blood vessel that drains blood away from an organ or tissue.
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Adrenal Gland Disorders
Benign Urethral Lesions
Bladder Diverticulum
Bladder Fistula
Cushing's Syndrome
Ectopic Kidneys
Extrinsic Obstruction of the Ureter
Hematuria
Hydroceles and Inguinal Hernias
Normal and Abnormal Sexual Differentiation
Renal Fusion (Horseshoe Kidney)
Spermatoceles
Urachal Anomalies
Ureterocele
Ureteropelvic Junction Obstruction
Urethral Stricture Disease
Vaginal Anomalies: Cloacal Anomalies
Vaginal Anomalies: Congenital Vaginal Obstruction
Vaginal Anomalies: Fusion and Duplication
Vaginal Anomalies: Urogenital Sinus
Vaginal Anomalies: Vaginal Agenesis
Varicoceles
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Welcome to the AUA's online patient information resource. UrologyHealth.org was written and reviewed by urology experts in partnership with the American Foundation for Urologic Disease. Visitors can search by choosing from adult or pediatric conditions, or by entering a condition using the search option. Content is accompanied by medical illustrations when appropriate. Additional content and illustrations will be added over time.
Today, as the world's preeminent urological association, the American Urological Association Education and Research conducts a wide range of activities to ensure that more than 13,000 members stay current on the latest research and best practices in the field of urology. An educational non-profit organization, the AUA pursues its mission of fostering the highest standards of urologic care by providing a wide range of services, including this website, publications, the Annual Meeting and numerous continuing medical education opportunities. The American Urological Association, Inc., a 501(c)(6) professional membership organization shares a dual corporate structure as well as membership and affiliations with the American Urological Association Education and Research, Inc., a 501(c)(3) charitable and educational organization. Health policy advocacy is a primary responsibility of our affiliated professional entity, the American Urological Association, Inc.
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