Varicocele Embolization
What is a varicocele?
A varicocele, pronounced var'e-ko-seel, is a network
of dilated blood vessels, or varicose veins, in
the scrotum. For unknown reasons, varicoceles
usually occur in the left testes. Varicoceles
are a relatively common condition that tend to
occur in young men, usually during the second
or third decade of life. This condition affects
approximately 15 to 20% of the general male population
and up to 40% of infertile males.
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How
did I get a varicocele?
Normally, oxygenated blood flows to the testicles
via an artery, and deoxygenated blood flows out
via a network of small veins that drain into another
vein, and is eventually carried back to the heart.
During this process, backflow to the testicles
is prevented by a series of one-way valves in
the vein. In some individuals, however, these
valves do not work well. As a result, the blood
flows in reverse and causes "back pressure" to
stretch and enlarge the network of small veins
around the testes, forming a varicocele.
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What
are the symptoms of a varicocele?
Many times a varicocele is silent and does not
cause symptoms. However, some varicoceles cause
a dull or aching pain especially when the person
has been in upright position for a long time.
Heavy lifting may also cause pressure build up
in the varicocele.
In some individuals, a varicocele may cause decreased
fertility or infertility. As many as 40% of men
with decreased fertility have a varicocele. A
commonly accepted theory is that the varicocele
raises the testicular temperature and adversely
affects the sperm count and quality. More than
half of men with decreased fertility will have
improvement in the sperm count and quality after
treatment of the varicocele.
In some men, varicoceles can cause shrinking
(atrophy) of the testicles. In many cases, when
the varicocele is treated on the affected side,
the testicle may return to normal size.
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How
is a varicocele diagnosed?
It is best to catch a varicocele before it can
cause major problems, such as infertility. Self-exam
of the scrotum is the best way to diagnose a varicocele
early. A varicocele can feel like a "bag of worms",
and is usually found in the left testicle. The
majority of varicoceles are detected by a doctor
during a health checkup.
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Do
I need to be treated?
In many cases, the varicoceles cause no symptoms
and do not need to be fixed. However, if there
is associated pain, decreased fertility, or testicular
shrinking, treatment may help. All adolescents
with varicoceles should be treated to avoid future
infertility.
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What
are the available treatments?
Varicoceles may be treated surgically by a urologist
(varicocelectomy) or by a minimally invasive method
(varicocele embolization) by an Interventional
Radiologist.
Embolization requires no stitches or general
anesthesia and only a 1/4 of an inch incision.
Nearly all the patients can be treated on an outpatient
basis and may return to normal activities in two
to three days. Surgical treatment requires an
incision and may require several days or even
weeks to return to full activities. Studies have
shown that embolization and surgery are equally
effective.
Regardless of the treatment, the varicocele may
recur and may require repeat treatment. If the
varicocele has been previously treated with surgery,
embolization is still an option. If recurrence
occurs after the embolization, embolization can
generally be repeated. If a repeat embolization
fails, surgery can still be performed.
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How
is the embolization procedure performed?
Varicocele embolization is usually performed on
an outpatient basis under sedation and local anesthesia.
A small catheter (tube) is inserted into a leg
vein near the hip or neck vein through a tiny
skin incision. This tube is placed into the varicocele
vein under X-ray guidance. Small amounts of X-ray
dye (contrast) are injected to confirm the position
of the catheter. Then tiny coils made of stainless
steel or platinum, balloons, or other materials
are inserted in the vein to block it and stop
the backflow, or pressure, in the varicocele.
Blood can still exit the testicle through other
normal pathways. Once it is confirmed that there
is no flow in the affected vein, the catheter
is removed.
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How
well does embolization work?
There is a 90% success rate with embolization,
and of those with success, about 10% may experience
late recurrence. These results are the same as
those achieved with more invasive surgical techniques.
Varicocele embolization has been performed for
over 25 years and has an excellent long-term safety
record. Its safety and effectiveness has been
shown in very large trials.
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Are
there any complications associated with varicocele
embolization?
As with any treatment, there are potential complications
associated with this procedure. Minor complications
such as bruising at the entry site, mild backache,
or nausea (rare) may occur. Complications associated
with surgery such as hydrocele (collection of
fluid in the testes), infection, or loss of testicle
are exceedingly rare with an embolization procedure.
Embolization does not affect sexual function.
Sexual activity may be resumed the day after the
embolization. However, since it takes sperm about
three months to mature, improvement in fertility
may take three months or longer.
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How
do I know which treatment will be the best for
me?
The best treatment for a varicocele depends on
whether or not you have had prior treatment for
a varicocele. You should discuss your treatment
options with your physician. Some questions to
ask:
- Is varicocele embolization an option for me?
- What are the risks and benefits of the treatment
plan prescribed for me?
- How do I pay for varicocele embolization?
The cost is similar to surgery. Most insurance
companies pay for the procedure. However, coverage
depends on the particular insurance company and
should be discussed with them.
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Reviewed by:
Aalpen A. Patel, MD
January, 2003
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