Varicocele

Few topics in medicine are as controversial and  discussed as varicocele and its significance in human pathology . But first of all, what is varicocele ? It is actually a varicose dilatation of the testicular reflue veins (pampiniform plexus, to the involvement of the internal spermatic veins), which has its highest incidence between the ages of 15 and 25. It affects about 10-20% of the overall male population and in 85% of cases is located on the left, while in a minority of situations it can be found on the right or on both sides.
But why does a varicose vein raise so much interest? Undoubtedly, the peculiarity of the site itself gives prominence to the disease , particularly if the varicocele is high grade (remember that, clinically, based on the size and visibility, the varicocele is ranked first to third grade). Although often asymptomatic , it can cause clinical symptoms ranging from a sense of heaviness up to sharp pain in the corresponding scrotal region. However, its potential relationship with infertility has undoubtedly placed it in a prominent position in male genitalia disease, a relationship that still brings it to the attention of andrological evaluation.

What are the pathogenetic mechanisms of varicocele ?
Over 95% of varicocele conditions are idiopathic (the so-called primary forms). The veins from the testicle, for embryological reasons, drain into the left renal vein and into the right vena cava; the upright position, evolutionarily acquired by humans, causes blood flow from the testicle to bear down on the spermatic veins, which are equipped with containment valve systems. It is possible that constitutional factors, similarly to what occurs in the veins of the lower limbs, can cause a weakening of the vein wall, with progressive bulging of the same , and this leads to a consequent valvular incontinence, conditioning the appearance of a retrograde reflux of blood that is salient feature of varicocele. The anatomy (angle of entry of the left spermatic vein into the renal vein; possible compression of the left spermatic vein by the mesenteric artery) accounts for the fact that this form of varicocele mainly affects the left side. It should be noted, however, that possible expansive retroperitoneal or pelvic processes compressing the venous structures can cause an obstruction of the venous outflow and the appearance of varicocele (in particular the appearance of varicocele in adulthood or on the right should suggest the exclusion of possible extrinsic compression diseases- secondary varicocele).

What are the symptoms of varicocele?
The symptomatology is strongly influenced by the degree of varicocele and its etiology . It is true that the majority of varicoceles are asymptomatic and are found incidentally during andrology diagnostic procedures for infertility or other disorders. The most frequent complaint made by patients with varicocele is a feeling of heaviness up to sharp pain in the corresponding scrotal region. It should be noted that in the rare cases of varicocele secondary to expansive retroperitoneal or pelvic processes, pain in these sites can be important.

How is varicocele diagnosed?
The diagnosis of varicocele is clinical and instrumental (echo-Doppler of the spermatic funicles). Clinically, it is possible to highlight the upright venous dilation of the pampiniform plexus, both in basal conditions and after provocation maneuver (the so-called Valsalva maneuver).  Ultrasnographic confirmation, in particular through echo- color Doppler of the scrotum which identifies venous reflux, is essential for diagnosing varicocele.

Varicocele and male infertility
The role of varicocele in male infertility is certainly the most controversial topic. Many arguments can be advanced for and against its involvement in impaired semen quality. Take, for example, the fact that varicocele may be present in subjects with normal semen characteristics (normospermic), although its prevalence is greater in patients with impaired semen characteristics (data from a study of the World Health Organization – WHO – 1992) . Several other studies have documented a negative effect of the presence of varicocele on sperm motility and morphology; the pathogenetic mechanisms involved may be the thermal effect due to increased scrotal temperature, increased pressure related to obstructed blood flow , excess of free radicals . The crucial question, though, is if correction of varicocele in men with abnormal seminal parameters would lead to improved characteristics of the semen itself and increase the probability of conception, evaluated by the so-called ” pregnancy rate”. Regarding this last important point, it should be noted that there are currently only seven randomized controlled trials on the effects of varicocele correction on pregnancy rate; of these, only one reports a statistically significant improvement in spontaneous conception after varicocele correction. Regarding the effect of varicocele correction on seminal parameters , controlled studies (that carry out a comparison with a ” control ” population in which the varicocele is not corrected ) reach conflicting conclusions, in that some studies provide data demonstrating an improvement in semen quality while others do not report significant changes. Any improvement in seminal parameters could, in itself, be useful for the purpose of optimizing male semen for couples who decide to resort to assisted reproduction techniques, in that the best semen quality may increase the likelihood of success of the same or reduce the degree of complexity of intervention (eg. intrauterine insemination rather than IVF, etc.) . Finally, currently available controlled data agree that it is highly unlikely that azoospermia (absence of sperm in the ejaculate) or severe oligospermia or cryptozoospermia are caused by varicocele .

To treat or not to treat varicocele ?
Worded this way, the question could almost be Shakespearean. In actual fact the answer depends on the type of patient and on the objective targeted (or rather on the expectation that is created) by varicocele correction. Some key questions from personal experience: is the person young ( 18-20 years old) or adult (> 30 – 35years ) ? Is he symptomatic or not? Is the purpose of varicocele correction to prevent possible seminal alterations in time, or to improve the potential for conception? In the latter case, how old is the partner, how long have they been trying to conceive and what are the couple’s ideas about possibly resorting to techniques of assisted reproduction? In actual fact, the case of a young 18 year old man with varicocele symptoms (eg. oppressive pain) and seminal alterations is certainly very different from that of a 40 year old asymptomatic man with modest asthenospermia, trying to conceive children year with his 38 year old partner.
The situations must therefore be assessed individually, depending on the specificity of the clinical case. However, there is broad consensus on the treatment of varicocele in the following conditions: i) adults and adolescents with varicocele symptoms (pain) , ii) adolescents with reduced left testicular volume > 2-3 ml compared with the contralateral (prevention) , iii) adolescents with 3rd degree varicocele and progressive deterioration of semen parameters in follow-up of 1-2 years , iv) male partners of couples who have been infertile for less than three years, with unexplained abnormal semen quality, with partners aged < 30 years (in the latter case attention should be paid to the fact that any access to assisted reproductive techniques should be scheduled within a year and six months after varicocele correction).
The patient should also be reminded that: i) it is unlikely to expect seminal improvement from varicocele correction in cases of azoospermia or severe oligospermia; ii ) recurrence of varicocele is possible; iii ) varicocele correction, in whatever way it is performed, is always an invasive maneuver and as such with possible complications.

How to correct varicocele ?
Correction can be performed: i) surgically, through ligation of spermatic veins using various techniques ; ii) via percutaneous scleroembolization, thus without surgical access. The choice of method will depend very much on the individual experience of the physician the patient goes to and with whom he addresses the issue.

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Giancarlo Balercia

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