Definition

Varicocele is a condition characterized by the enlargement of veins located inside the skin covering the testicles, known as the scrotum. These veins play a role in transporting blood with low oxygen levels from the testicles back to the heart. When there is a disturbance such as enlargement of the veins within the scrotum, blood cannot flow out properly, leading to a buildup of blood in the vein, resulting in varicocele.

Varicocele commonly occurs in males starting from puberty and can develop as they age. It is frequently found in males aged 15-25 years old. This condition affects around 15% of adult males and approximately 35% of males with primary infertility issues.

In most cases, varicocele does not cause problems. However, if left untreated and leading to complications, it can result in testicular development disorders, decreased sperm production and quality, and can be one of the factors contributing to infertility. The size of the testicles may also decrease, although it should be noted that not all varicocele cases will affect sperm production.

Causes

There are 2 arteries and 2 veins in the scrotum, which play a role in receiving and delivering oxygen. There are small vein networks called the pampiniform plexus on each side of the scrotum. These small vein networks function to deliver low-oxygen blood to the main testicular veins. Swelling of the pampiniform plexus can cause varicocele.

The exact cause of varicocele is still not fully understood. One suspected factor in causing varicocele is damage to the valves in the veins, preventing blood from flowing back to the heart and causing it to accumulate in the veins. Additionally, the veins in the left scrotum have a slightly different pathway from those in the right scrotum, making them prone to blood accumulation in the left scrotal veins.

The scrotum maintains an optimal temperature for sperm production and development. Varicocele can raise the temperature in the scrotum, potentially disrupting sperm production and function. Varicocele develops gradually. As sperm production and quality decrease, in severe cases over time, varicocele can lead to infertility issues.

Risk Factor

As of now, there are no specific risk factors that can cause varicocele. Varicocele is not associated with specific diseases, race, place of birth, or specific ethnic groups. Although varicocele is often found in men experiencing infertility issues, about 8 out of 10 varicocele patients do not have infertility.

Symptoms

Most varicocele patients typically experience discomfort in the left testicle due to anatomical differences on both sides of a man's body. Although rare, varicocele can sometimes be found in the right testicle or occur in both testicles.

Usually, varicocele patients may not experience any symptoms at all. However, there are some possible complaints, including:

• Pain or discomfort felt directly in the scrotum when standing or at certain times. Generally, lying down can relieve the pain
• Swelling of the testicle or scrotum and enlargement of the veins may appear like a bag of worms. Swelling in small varicoceles may not be very noticeable and may need to be touched to be detected
• Difference in testicle size. Testicles affected by varicocele usually have a smaller size compared to the other testicle
• Complaints may worsen after certain activities, such as cycling or walking for hours.
• Infertility in some cases

Diagnosis

The diagnosis of varicocele is established through interviews regarding patient complaints and medical history conducted by the doctor. Then, the doctor will perform a physical examination in the patient's genital area. The doctor will visually inspect or directly observe the area around the scrotum. The doctor may also touch the scrotum to confirm if there is swelling and compare each side of the scrotum. Examinations can be done while lying down or standing.

Additional diagnostic tests that can be performed include a scrotal ultrasound examination. Ultrasound examination uses ultrasound waves to clearly visualize the veins in the scrotum and testicles. Ultrasound can help the doctor confirm the diagnosis of varicocele, identify enlargement of veins, and see if there are any other blockages in the scrotal blood vessels.

The doctor may also recommend sperm analysis and blood tests if concerned that varicocele may affect your fertility.

Management

Treatment of varicocele is usually tailored to the patient's condition. In adolescents or young adults where varicocele does not cause complaints, treatment may not be immediately necessary. The doctor will recommend regular checkups to ensure the patient's condition is monitored. Surgical procedures are usually only recommended if the patient experiences the following:

• Chronic pain and complaints that significantly affect the quality of life.
• Testicular growth and development are hindered.
• Decrease in sperm count or abnormalities in sperm quality.

In some cases of infertility, surgery can be performed to repair blood vessels. This surgery, called varicocelectomy, is performed to redirect the blocked veins to healthy veins. The expected outcome of this procedure is to improve the testicles so that the scrotum returns to its normal size and to increase sperm count and normalize sperm quality.

The doctor will provide pain relievers and antibiotics before and after the surgery. Post-operative pain will improve within days or weeks. Afterward, the doctor will still request regular checkups, usually within 1-2 weeks after surgery.

Complications

Complications of varicocele typically occur in the testicles. The accumulation of blood in the veins over time can disrupt temperature regulation in the scrotum and lead to the accumulation of oxidative stress and toxic substances. Complications of varicocele that may occur include:

• Testicular Disorders

Varicocele occurring in adolescent males will affect testicular growth and function in producing hormones and other substances, potentially resulting in testicular size reduction.

• Infertility

Approximately 10-20% of males with varicocele may experience infertility problems. However, it's important to note that not all fertility issues are caused by varicocele. Infertility due to varicocele is typically diagnosed when a couple fails to conceive after 1 year of regular unprotected sexual intercourse.

Although surgery is one way to manage varicocele, there may be risks associated with the procedure, such as:

• Fluid accumulation around the testicle (hydrocele)
• Recurrence of varicocele in the future
• Infection
• Artery damage
• Prolonged testicular pain
• Blood accumulation around the testicle (hematoma)

Prevention

As the exact cause of varicocele is still not fully understood, there are no specific preventive measures that can guarantee its avoidance.

When to See a Doctor?

Seek medical attention if you or your child experience any of the aforementioned symptoms. Undergo regular checkups to monitor your health condition. Additionally, self-examine your genital area regularly to detect any unusual changes and consult a doctor if needed.

Some warning signs that warrant immediate medical attention include shrinking testicle size, abnormal sperm analysis results, and failure to conceive a child after a year of regular unprotected intercourse.

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