A varicocele is a condition caused by dilated veins around the testes. Patients are usually born with them, and they become evident at puberty. They are the result of incompetent valves in the veins that lead to pooling of blood around the testes. The testes function better at a lower temperature than the rest of the body, and that’s why they are outside the body in the scrotum (sac). When exposed to cold, the scrotum contracts, and when exposed to heat, the scrotum relaxes. This is a regulatory mechanism. In the case of a varicocele, the temperature within the scrotum is typically higher than it should be. A varicocele even if found on one side (usually on the left in most men) is considered a bilateral disease. This is because the septum that separates the two testis is thin, and the increase in temperature on one side exposes the other testis to that increase in heat. Varicoceles can be progressive, meaning in their untreated state can continue to adversely affect testicular function. There is a lot of data on varicoceles in the literature. Larger varicoceles have more of an effect, and vice versa.

During the visit, patients are examined lying down and then standing up. While they are standing, they are asked to strain. This maneuver makes the palpation of the varicocele the easiest. If the exam is borderline, then I will order an ultraosound. (An ultrasound is a non-invasive way of checking the veins and blood flow in the testis, as well as its anatomy.) In addition, if I feel a varicocele on one side and the other side is equivocal, I will also order a scrotal ultrasound. If the varicocele is clearly palpable, or the veins measure 3 mm or more, or there is reversal of flow, I will fix the varicocele(s). If both sides are palpable, then the ultrasound is unnecessary. Sperm counts may transiently drop post-operatively. Improvement is typically seen at six months, and sometimes earlier.



The most important question to answer is, who needs a repair of their varicocele? Not all doctors practice the same. Even if two patients are the same with respect to their sperm count, hormone levels, and varicocele, they may be treated differently. In my practice, we have patients who typically have children when they are older, and the maternal age will often dictate how the male patient is treated. That said, patients whose varicoceles are palpable are candidates for varicocele repair, as are those whose exams are equivocal, but have a minimal diameter of 3 mm of their veins, or a reversal of blood flow in these veins during scrotal ultrasound. I will decide with you whether to do this procedure. The procedure is a microsurgical subinguinal varicocelectomy.

A small incision is made below the location where hernia surgery is done, just to the side of the penis and above the scrotum. No abdominal wall muscle is cut during the surgery. The spermatic cord (the area of nerves, veins, arteries, and the vas deferens) is identified and brought into the surgical field, and any adjacent veins to the cord are tied off. The microscope is brought in and the cord is opened, exposing the vessels, vas, nerves and lymphatics. The cord is dissected, and the artery or arteries are preserved. The veins are identified and tied off. The vas is identified and examined. If the vasal vein is less than 3 mm, it is preserved; if it is 3 mm or more, it is tied off. While great care is taken to preserve the testicular artery, there are two other sources of blood supply to the testis, so it will still be viable if the artery is cut. At least one lymphatic vessel is identified and preserved. A microscopic Doppler is used to preserve the artery at the time of surgery. The surgery is done meticulously. When finished, everything is checked twice, and the cord is closed. The area behind the cord is once again checked for accessory veins. The area is checked for any small bleeders, and the skin is closed in two layers. No sutures need to be removed.

Any time a patient has surgery, there are three possible outcomes. You get better, you get worse, or you remain the same. The goal of the surgery is to improve the count and the semen parameters such as motility (sperm movement) and morphology (sperm shape). It has been suggested that, even without any numerical change in analysis, the sperm quality is better. Like all other surgeries, a varicocelectomy has possible complications. Any time a patient has surgery, any surgery, infection, pain and bleeding may occur. Complications specific to a varicocelectomy include testicular and vasal injury (vas deferens), hydrocele (fluid around the testis), and hematocele (blood around the testis). A decline in sperm parameters and count may occur, but are unlikely. Finally, anytime the skin is cut, it can lead to a change in sensation and possibly local numbness. The overall risks are quite low, and in the less than 5% range. This operation involves general anesthesia, and any related questions or concerns you have should be discussed with the anesthesiologist prior to the surgery.