Varicoceles are a collection of dilated veins around the testicle. They are common and occur in about 1 of 10 men, usually 20-40 years of age. They can cause testicular pain, testicular atrophy, and infertility. Veins carry blood from the testicle back to the heart using a series of one way valves that control the direction of blood flow. When these valves fail, blood moves in the wrong direction and the pressure inside the veins increases and the veins dilate, forming a varicocele. A varicocele is akin to varicose veins of the leg. Varicoceles more commonly involve the left testicle.
As varicoceles increase in size the abnormal veins can cause testicular pain. The pain usually gets worse during the daytime and is aggravated by activity, especially heavy lifting. The abnormal veins can also affect fertility by increasing the temperature of the testicles which affects sperm production. In adolescent males, varicoceles are a common cause of testicular atrophy and may negatively affect future fertility.
Varicoceles are diagnosed during clinical examination and are confirmed by testicular ultrasound. Testicular ultrasound is important for evaluating the testicle, determining testicular volume (size) and documenting the size and extent of the varicocele and the abnormal blood flow (reflux).
There are 2 treatment options. Varicocelectomy or varicocele embolization.
Varicocelectomy is a surgical procedure where the abnormal veins in the groin are tied off. The procedure involves groin incisions and is often done under a general anesthetic.
Varicocele embolization is a minimally invasive procedure with no groin incisions. The abnormal veins are blocked off through using small metallic coils. The procedure is done with local anesthetic and some mild sedation.
There is controversy as to which procedure is best with urologists advocating varicocelectomy and interventional radiologists advocating embolization. The advantages of embolization over varicocelectomy are obvious:
- No groin incisions
- Less post-operative pain
- Faster recovery time
- Bilateral (right and left) varicoceles can be treated while surgery requires 2 groin incisions
- Lower complication rates, especially infections
- No general anesthesia
- Faster return to work and active daily living
It seems obvious that varicocele embolization should be the first treatment of choice and yet most patients are not referred for embolization or not even told about embolization. This situation is similar to gynecologists not referring patients for uterine fibroid embolization as an option to hysterectomy. Too often, urologists quote misleading statistics or give bad information about embolization.
When done by an experienced interventional radiologist, the outcomes of varicocele embolization are excellent.
I reviewed the last 37 patients who came to me for varicocele embolization because of testicular pain, infertility or both. All patients had a pre-procedure ultrasound documenting a testicular varicocele. 18 patients under went left varicocele embolization and 19 patients had bilateral (right and left) varicocele embolization. No patient had an isolated right varicocele.
Left varicocele embolization was performed 37 times. In all of these procedures, the varicocele was successfully embolized. One of the 37 patients required a second procedure as the first attempt was not successful. Overall, my technical success rate for left sided embolization is 100%. In the published literature this rate is around 90-95%.
Right varicocele embolization was performed 19 times. 18 of the 19 embolization procedures were successful. In one patient, I was unable to find the right testicular vein to complete the embolization. My success rate is 95%. This compares favorably with other published data showing success rates of 60-80%.
Of the 37 patients, clinical follow up and post procedure US was obtained in 33 patients. 4 patients were lost to follow up. On ultrasound, reflux was eliminated in 31 patients, with 2 patients having > .5 seconds of reflux. Of the 33 patients treated, 31 had complete resolution of reflux. 94% of patients with varicoceles were successfully treated with embolization.
Of the patients treated for testicular pain, 25 of 31 patients had resolution of pain (80%). 6 patients had testicular pain that did not resolve. Testicular pain can have multiple causes and correction of a varicocele may not relieve the pain. My success rate of 80% compares favorably with the published literature.