Paediatrics Urology Unit
Prostate Growth And Greenlight Method
Premature Ejaculation (Early-Fast-Rapid Ejaculation)
Penile Prosthesis İmplantation
Sexually Transmitted Diseases (Venereal Diseases)
Testicle And Epididymis İnfection
• Assoc. Prof. Ömer ÖGE, MD
• Işık H. ÖZGÜ, MD
• Uğur SARAÇOĞLU, MD
What is varicocele and how often it is seen?
This is a type of vein mass consisting of extraordinarily enlarged veins inside varicocele scrotum (skin pouch inside testis). This resembles to varicose occurred in legs and this is the most frequent disease in men complaining of having no child.
What are the symptoms of varicocele?
This does not cause a clear complaint in each patient on general terms. Varicocele frequently occurs in left testis due to different anatomic characteristics of male body (60-80 %) and it is observed in both testis in the rate of 20-40 % and it can be very rarely observed in right testis. Since it occurs in puberty ages, it slows down the testicle where it is located and it may cause testis size to remain slightly small when compared with the other. Patients sometimes state that they have "pain" or "discomfort" in the testis with varicocele. In advanced cases, a person may distinguish swollen veins with eyes. Varicocele is usually detected with a physical examination conducted by a urologist when testis pain occurs or examination of men complaining for it and visiting the doctor with generally fertility problem case.
This may be seen depending on obstruction of venous drainage of one sided right varicocele testis emerged in future years.
Especially left sided varicocele may occur depending on advancement of vein of kidney of kidney tumour in the future years.
How Varicocele is diagnosed?
Expanded vein mass over testis looks like a bag filled with worm and a patient may distinguish this by himself with an examination or it may be detected by outpatient examination of your testis by the physician. In advanced phenomena, expanded veins become visually visible outside. Diagnosis of varicocele is performed with physical examination and additional monitoring methods are not needed for diagnosis. Physical examination can be performed by hospitalization and as outpatient procedure. While especially patient is outpatient, patient is requested to increase his intra-abdominal pressure and whether veins in scrotum are inflated or not. Varicocele identified in physical examination is called "clinic varicocele".
In addition to this, the physician may require analysis of colour Doppler ultrasound for the purpose of placing a final diagnosis:
• Non-specific varicocele in examination
• Patients with his testis placed upward of scrotum
• Patients with small scrotum bag
• Failure of performing appropriate and sufficient examination due to patient state or environment and cremasteric hyperreflexia obstructing physical examination.
It is believed that varicocele detected with only colour Doppler ultrasound analysis but not detected in physical examination is not clinically very significant because physical examination is primary method in diagnosis procedure. This state is called "subclinical varicocele".
Measurement of testicular volumes in the infant and adolescents is of high importance in terms of necessity of treatment and monitoring procedure. This measurement can be conducted with either ultrasound or orchidometry.
Does each man with varicocele have infertility problem?
Each man with varicocele does not have infertility problem. But, this is the most frequently detected disease in men complaining of not having a child. Adverse effects of varicocele over sperm production can be performed by conducting semen analysis. Minimum two semen analyses should be conducted for understanding whether varicocele disrupts semen parameters or not. Duration between two semen analyses should not be less than 7 days and more than 21 days.
If a problem is detected in semen analysis results of the persons with infertility problem together with varicocele, hormonal and genetic study should be conducted in some portion of these patients abut conducting this study in each is not a stipulation. Serum testosterone and FSH (follicle stimulating hormone) levels are conducted in the persons with hormonal diseases suspicion in medical story and complaining of absence of sexual appetite and with sperm count less than 10 million/ml. Patients with varicocele having sperm count less than 5-10 million/ml are informed about potential genetic disorders and karyotype and Y chromosome analysis may be applied to these phenomena. Varicocele detected in mean bearing a genetic disorder is a potentially incidental finding and it should be known that varicocele treatment will not resolve fertility problem.
Semen analysis results following varicocele operations are frequently corrected and some portion of patients can have a child via a natural way.
Course of Varicocele Disease
Disease usually does not cause symptoms and it is usually detected in the examination of male examined and complaining for due to fertility. This is noticed as a result of coincidence during physical examination or by families during infancy or puberty. In this age group, disease does not frequently produce symptoms. Diagnosis is made like as in adults and there is no need for additional monitoring methods. Testis volume should be measured following physical examination. This measurement can be either conducted with orchidometry or ultrasound.
Varicocele may cause infertility by disrupting sperm production and diminishing testicular development by way of progressive testicular damage. It especially reduces sperm count in adult ages and disrupts mobility and structure of sperm and decreases testicular volume. More rarely, it causes reduction in hormonal production capacity of testis in the long run.
How should varicocele be treated?
Varicocele may not be treated at all times. Before deciding on treatment, it should be investigated whether there is another problem that will obstruct the patient to have a child rather than varicocele and it should be demonstrated that female partner has normal fertility potential. If you and your spouse want to have a child and the following conditions are in question, you should consider being treated:
• If your varicocele is felt in scrotum examination of your doctor (clinical varicocele),
• If you did not have a child although you had a regular sexual intercourse minimum one year,
• If there is no fertility problem in woman or there is a treatable fertility problem,
• If your consecutive semen analysis results conducted hereof are not normal,
• Single adult men contemplating to have a child in the future and having disrupted semen analysis results should consider treatment.
• Varicocele has an influential role in men having pregnancy or child but then having infertility problem. That varicocele is identified in these persons in the rate of 69-81 % demonstrates that varicocele is a progressive disease and previous having a child capacity over time may result with loss of this capacity. Treatment is recommended to these persons.
• If you are a young man and you have no complaint (pain or fertility problem) and your semen analysis results are normal, you should be monitored by a urologist with physical examination and semen analysis once a or two years.
• If there is contraction in testis size in puberty age (volume loss more than 10 %), softening in testis consistency, disruption in sperm parameters (if semen sample can be provided) and varicocele is two sided and patient has much paint, operation is recommended. If these above-mentioned situations do not exist and you do not want to have an operation, you should be monitored with semen analysis and physical examination once a year. Monitoring range can be lowered to once a 6 month in phenomena detected with increase in degree of varicocele.
• Varicoceles detected in childhood age should be treated with operation since likelihood of damaging of testis in long run is relatively much more.
• Since effects of treatment of subclinic varicocele are not proven over pregnancy rates and semen parameters, it is recommended that it should be monitored without treatment. Note that there is a possibility of disruption of semen parameters following a subclinic varicocele operations conducted in sufficiently in addition terms.
• In case of only presence of discomforting pain of a patient, other diseases likely to cause pain before treatment should be investigated; underwear supporting testis worn by tools together with pain sedative drugs for a while should be used and pain should be attempted to be treated. In case complying with these criteria, success of varicocele operation conducted for pain is higher.
How varicocele disease is treated?
Treatment of the disease is surgical intervention. Expanded veins are connected in the operation conducted by urologist. There are a few different surgical treatment options. Today's state-of-the-art operation technique is the operation performed by micro-surgery and it has been proven that it is more effective than other methods with the studies conducted. In case of repetition of the disease, corrective surgery can be performed with micro-surgery to those having undergone unsuccessful varicocele operation with legacy methods. Operation is performed with general or local anesthesia. One sided micro-surgery varicocelectomy operation is performed within approximately one hour by experienced surgeons. You can generally go home on the same day. Pain is not much after operation. Patient quits works for 2-3 days and rests at home. Your physician will follow you during minimum 1 months once 3 months or until you have a child. If you cannot have a child, auxiliary reproductive techniques should be considered.
All effects of surgical treatment of varicocele over fertility have not been revealed yet. While some studies demonstrate that this rectifies infertility, there are some facts that demonstrating that there is no effect at all. In addition to this, most of the couples having infertility problem prefer to be treated because:
• Semen analysis results of most of the men get fine after operation.
• Varicocele treatment may resolve infertility problem.
• Serious risks of operations are almost very few.
• Moreover, there are scientific studies based on proof evidencing that fertilization rates have increased in patients for whom vaccination and in vitro fertilization should be performed.
• If you have only pain compliant, your physician may prescribe you some medications mitigating your pain and swelling in your testis. Underwear supporting your testis worn by athletes may help in reducing your pain.
What are the indicators for positive response in varicocele treatment?
• Presence of severe varicocele
• Normal or close-to-normal testicular volumes
• Normal FSH testosterone, low inhibin B levels
• Total movable sperm count is over 5 million
• Normal genetic tests
• Short duration of infertility
• Failure to detect molecular abnormalities
Which one is suitable or right for patient in varicocele operation or auxiliary reproductive techniques?
It is not always easy for giving a full response for you and your spouse. In the first place, your physician will help you with this, but many factors play a role in giving a decision and you should consider the following while giving a decision:
Varicocele operation: You can have a child by natural means. Requirement for reproductive auxiliary treatment methods may reduce with varicocele treatment.
Auxiliary reproductive techniques: This is conducted for each pregnancy.
Fertility of your spouse: Women's fertility capacities start to decline after the age of 35 .
Untreated varicocele: If varicocele occurred in young ages fails to be treated, as you grow older, your semen quality reduces and your chances of having a child will decrease in the future.
In cases where the pregnancy is not automatically ensured with varicocele treatment, it may be switched to easily applicable and less costly reproductive auxiliary treatment methods instead of costly methods such as IVF/ICSI with recovery based on pre-treatment values in sperm parameters.
Through varicocele treatment, number of sperm, movement and structural recovery may boost success of reproductive auxiliary treatment methods.
If man's semen analysis is damaged and his spouse is normal, varicocele repair can be considered as the first option. If auxiliary reproductive techniques such as IVF treatment are needed for treating woman factor, these techniques such as the first option can be considered.
Via micro-surgical method, thins veins not seen with naked eyes are identified and connected; spermatic and cremasteric arteries feeding testis are distinguished and protected and are not connected. Testicular artery injury or ligation leading to disruption risk in testis atrophy and/or sperm production is one of the varicocelectomy complications. In addition to this, our body incorporates a lymphatic circulatory system that is a type of fluid circulation inside and working as third vascular vein system. Lymphatic vessels are so thin that they cannot be seen with naked eye. Protection of this vessels is of utmost importance in terms of avoiding hydrocele complication likely to occur after operation. While hydrocele is seen in the rates up to 10 % in open surgery with no micro-surgery implementation, rate of occurrence of this complication in micro-surgical varicocelectomy drops to 1 %.
While repetition rate of the disease in the methods to varicocelectomy is applied with naked eye is around 15 %, this rate in micro-surgery series is around 1 %. The scientific studies conducted have demonstrated that pain complaint of the patient with varicocelectomy operation has healed and semen analysis results have recovered and the couples can have a child. Semen parameters in 80 % of the patients can be recovered. The most frequently recovered parameter after operation is semen mobility and this is followed by increase in sperm count.
Patients with especially high degree varicocele prior to operation have more benefits when compared with the patients with low degree varicocele. It has been demonstrated that testosterone levels are recovered after micro-surgical varicocelectomy with low serum testosterone level are recovered. Besides, it has been proven that pregnancy rates in the group to which operation is applied as a result of monitoring group to which it is not applied with group with operation implementation are higher. It has been found out that conception rate in the first year is 43 % following operation conducted with micro-surgical method in the study conducted and 69 % in the second year. In this study where 1500 patients are evaluated, disease has been only recurred in one patient in this study; no complication such as contraction in testis and hydrocele has been seen.
Artery and lymphatic vessels are protected with micro-surgical technique and less damage is given to tissue and recovers after operation is in faster process. Operation can be performed as daily surgery.