Varicocele, testicular and scrotal varices The Phlebology Clinic / Pelvic venous insufficiency in men / Varicocele, testicular and scrotal varices Introduction Description of the condition Risk factors Recognition and diagnosis Treatment methods Frequently asked questions Introduction Varicose veins of the spermatic cord (varicocele), also colloquially known as 'testicular varicose veins', are dilated and tortuous veins in the scrotal sac that are unable to drain blood cephalad, i.e. towards the heart, due to insufficiency. It is important to remember that the term varicose veins of the scrotal sac (Intra-scrotal) is a broader term, encompassing all types of varicose veins in this area, not just seminal varicose veins. Vestibular varices are by far the most common type of intra-scrotal varices. They are more common on the left side. The condition is common. It affects approx. 15-20% adult males and to 40% men struggling with infertility. In adolescents, the risk of developing varicose veins of the seminal vas deferens increases during puberty, which is the period of body growth and increasing strength loads. The incidence of varicocele is less than 1% in boys under 10 years of age, but approaches the values observed in the general adult population (approximately 15%) during adolescence. Although varicocele often does not cause significant clinical symptoms, it can lead to discomfort in the casts of the inguinal canals and scrotal sac, as well as affecting fertility. Description of the condition Varicose veins of the spermatic cord are the excessively dilated, tortuous and elongated veins that form the choroid plexus. Under physiological conditions, the choroid plexus is responsible for the outflow of blood from the testicular area into the systemic circulation (veins draining blood to the heart). When the testicular veins (more often the left) are dilated and insufficient, blood backs up and stagnates within the veins of the choroid plexus. Vestibular varicose veins in young adults most commonly affect one side of the body - in approximately 90% cases, the left testicular (gonadal) vein runoff is initially affected. Used for years Dubin-Amelara classification used to assess the severity of seminal varicose veins is of little use in the modern era of knowledge about their formation. Assessing the size of seminal varices by palpation does not relate to the severity of the problem. In daily practice, a thorough haemodynamic and morphological analysis using modern imaging methods is used and, on this basis, classifies the types of truncal and truncal venous insufficiency while referring to other systems: the inferior vena cava, iliac, lumbar, spinal or other venous vessels of the retroperitoneal space and veins of the lower limbs. Examples of anatomical types of the nuclear vein in cases of insufficiency of its drainage. A system with a single trunk and drainage into the left renal vein occurs in only about 30% cases. The varicoceles of the seminal vas deferens resemble in appearance and touch a sac filled with 'longitudinal worms'. Only approx. 30% men report symptoms directly related to venous stasis in the scrotal sac. These include: pain or discomfort in the scrotum, exacerbated by standing, exercise or high temperatures; dilatation of the scrotal veins visible through the skin; a feeling of heaviness or pulling in the scrotum; reduction in the volume of the testicle on the side where the varicocele is present; swelling and warming of the scrotal sac (L>P). The size of varicose veins does not always reflect the degree of haemodynamic disturbance and generally correlates poorly with clinical symptoms and prognosis. Therefore, in the Department of Phlebology, the main importance is attached to the ultrasound assessment performed in the examination of the Doppler ultrasound of the abdominal veins, pelvis, pelvic floor and scrotal sac using Doppler techniques. Evaluation of the scrotal sac on ultrasound alone is insufficient to qualify the patient for treatment. In adult men, varicose veins of the seminal vas deferens are one of the most common causes of male infertility. They are estimated to occur in approximately 40% men diagnosed with infertility. Their negative impact on semen quality concerns a number of parameters. In the semen examination, a reduction in the total number of spermatozoa, their concentration, their motility is reduced and their structure is abnormal. It should be borne in mind that the mere presence of varicocele is not synonymous with infertility, especially if it is only present on one side. Risk factors that increase the incidence of varicocele anatomical disadvantages - e.g. hypoplasia of the left renal vein, abnormal flow of the nuclear veins, low density of venous valves, etc. male height (especially for those over 190 cm) genetic predisposition related to the weakness of the vascular wall and the structure of the venous valves sedentary lifestyle, lack of regular physical activity abdominal obesity associated with fat deposition in the inguinal canals overuse of strength training scrotal skin overheating (sauna, hot baths) chronic constipation frequent cycling complication after surgical procedures on the scrotum and the spermatic cord Extended left seminal varicocele in a patient who abuses the gym a daily basis. One of the more common causes of varicocele these days. Mechanism of formation The mechanism of varicocele formation is complex and multifactorial. It is underpinned by both anatomical abnormalities (e.g. stenosis of the left renal vein) and functional abnormalities relating to the need for anti-gravitational outflow of venous blood from the scrotal sac towards the heart. If we add to this the prevalence of increasingly taller and more obese men in society who over-exercise, we can understand why varicose veins of the seminal vas deferens are becoming an increasingly common problem for modern men. It is noteworthy that while the pressure in the veins on the right and left sides is similar in the supine position, in the standing position the hydrostatic pressure in the left nuclear vein is higher due to the vertical course of the vein and the higher outlet to the renal vein than happens on the right side. This explains the much higher incidence of varicocele on the left side. Limb venous leakage at the level of the insufficient nuclear veins: right and left. Digital phlebography performed in the Vascular Laboratory of the Department of Phlebology. According to the research work of the doctors of the Department of Phlebology, the influence of the male form of pelvic venous insufficiency (including seminal varicose veins) on the occurrence of limbic venous insufficiency is crucial. This is why, so often, in patients with testicular venous insufficiency and venous plexus overload of the seminal vas deferens, we find secondary limbic venous insufficiency. Diagnosis and diagnosis of varicose veins of the spermatic cord When proceeding to diagnosis intra uterine varices, it is important to realise that they are a symptom of the male pelvic venous insufficiencyand not the disease itself. Most diagnostic and qualification errors for their treatment are precisely due to the fact that this aspect is overlooked and only an examination is carried out at the diagnostic stage Ultrasound of the scrotal sac. When diagnosing varicose veins of the scrotal sac, it is important to remember that we are addressing a much broader problem than a phenomenon that only affects testicular atrophy and fertility. Long-term pelvic venous insufficiency with coexisting varicose veins of the spermatic cord may also cause: venous stasis in the perianal plexuses, sexual dysfunction (e.g. adversely affecting erection), bladder dysfunction or, finally, cause secondary limb venous insufficiency with varicose veins on the legs. The initial diagnosis of varicocele is based on a thorough patient history and physical examination. Central to the initial diagnosis is a physical examination with viewing and palpation of the scrotum and seminal vas deferens. The examination is carried out both standing and lying down, assessing the scrotum at rest and during the Valsalva test. This is a skill that every paediatrician should master. Diagnosis of the male form of pelvic venous insufficiency requires a broader and holistic view and assessment of the pelvic venous circulation and the pelvic abdominal cavity. An initial assessment of the lower limb veins is also important. For this reason, the examination of choice for suspected pelvic varicose veins is the Doppler ultrasound examination of the abdominal and pelvic veins with assessment of the perineum and scrotal sac in the standing and supine positions. In the case of clinically significant abnormalities, a dilated diagnosis is also necessary in patients qualified for treatment to exclude secondary causes of pelvic venous insufficiency and organ changes that may have a significant impact on the treatment of varicose veins of the vagina. The dilated diagnosis most commonly uses CT venography (CTV) or MR venography (MRV), in which the vascular and organ anatomy is carefully assessed and significant associated pathologies are excluded. After digital phlebography The descending imaging technique is rather reached at the intraoperative stage. Varicose veins of the seminal vasculature on examination: (1) MR venography, (2) CT venography, (3) digital phlebography, (4) Doppler ultrasound. Author: Cezary Szary Historically, the traditional division of varicocele included 3 steps depending on their clinical stage (stage I: palpable only during the Valsalva test; stage II: palpable in standing position with free breathing; stage III: visible through the skin of the scrotal sac) Nowadays, this division is already of historical relevance, as it is always crucial to assess the cause and extent of venous reflux, to evaluate the overload of the internal iliac veins and the sites of transmission of pelvic insufficiency to the veins of the lower limbs. The size of the nuclear veins and varicose veins alone is not that important, as it does not reflect the haemodynamic relationships. Treatment options for varicose veins of the genital tract The choice of the optimal treatment method for varicocele depends on the severity of the disease, the severity of the symptoms, the patient's age and individual preferences. The modern approach to treating this condition is based on a comprehensive clinical assessment and the use of minimally invasive techniques that allow a rapid return to daily activity. At Phlebology Clinic We focus on an individualised approach to each patient. Our team offers a full range of treatment methods - from conservative management, through classical surgeries (in cooperation with experienced urologists), to modern and proprietary endovascular procedures. Conservative treatment For small varicose veins of the seminal vagina and in the absence of complaints, conservative treatment may be sufficient. This is especially true in very young patients, in whom embolisation procedures are performed at 17-20 years of age. Conservative management consists of lifestyle modification and reduction of risk factors. Recommendations are: regular physical activity (no weight-bearing exercise), avoidance of prolonged sitting or standing keeping an eye on the correct body weight avoiding overheating of the scrotum (hot baths, sauna) wearing loose underwear to support the scrotum. Intravenous surgical treatment The modern approach to the treatment of varicose veins of the vagina (which are a symptom of pelvic and abdominal venous insufficiency) focuses on the use of minimally invasive (intravenous) techniques, providing the possibility of causal treatment, a much higher high success rate and faster recovery. Intravenous embolisation is the most effective and least invasive method of treating varicose veins of the spermatic cord. It consists in closing the insufficient veins from the inside (e.g. the trunk of the left testicular vein and secondary varicose veins of the seminal vagina), without the need for a skin incision. The procedure is performed under local anaesthesia, from a percutaneous access, which minimises pain and discomfort for the patient. Embolisation of varicocele - how does the procedure work? Embolisation of varicocele - a modern, minimally invasive and effective treatment option! ✨ See how we perform this procedure, learn about the advantages and see why you should choose this option. During venous embolisation, the doctor inserts a special catheter into the diseased vein and then, under X-ray guidance, places embolisation spirals or special agents that obliterate (close) the diseased venous vessels in the vessel. These substances permanently block blood flow in the diseased vein, eliminating reflux and the cause of varicose veins. Venous embolisation is particularly effective in the treatment of varicose veins of the spermatic cord caused by anatomical compressions and venous malformations, e.g. hypoplasia of the left renal vein or May-Thurner syndrome, where traditional surgical methods prove ineffective. The advantages of the venous embolisation procedures performed for the treatment of varicose veins of the genital tract by the doctors of the Phlebology Clinic are: minimally invasive: no surgical incisions, local anaesthesia high effectiveness: permanent elimination of reflux and varicose veins short recovery time: rapid return to physical and sexual activity (usually 4-10 days) the possibility of treating haemodynamically and anatomically complex cases (there the urological-surgical approach) is not very effective. Surgical treatment of varicose veins of the spermatic cord In the past, treatment of varicocele was based on surgical techniques, limited to ligation of the incompetent testicular vein. Nowadays, these methods are being superseded and replaced by intravenous treatment, which is characterised by higher efficacy, less burden on the patient and faster recovery and, most importantly, the possibility of causal treatment. In Poland, the standard of treatment in hospitals is still symptomatic varicose veins of the genital tract surgical treatment remains. Operative techniques used include: the Palomo operation - Ligation of the nuclear vein at a high level (retroperitoneal access) - an exiting method; Ivanissevich operation - involves the ligation of the vas deferens from a trans-peritoneal approach. Unlike the Palomo operation, it does not require opening of the abdominal cavity and preparation of the retroperitoneal space. microsurgical varicocelectomy - Selective vein ligation using an operating microscope; laparoscopic varicocelectomy - Ligation of the nuclear vein drainage using a laparoscope. Endoscopic treatment of varicocele is being displaced by intravenous techniques. At the Phlebology Clinic, we focus on modern, minimally invasive methods of treating varicose veins of the spermatic cord, with particular emphasis on endovascular proceduressuch as venous embolisation, venoplasty or venous stenting. The choice of endovascular techniques is dictated by a number of benefits, which include: high efficacy, low risk of complications (higher safety profile), faster recovery and good cosmetic outcome, and a greater range of effects on the rest of the venous system (reduction of descending overload mechanisms in the internal iliac and leg veins). Mostlyquestions asked Is treatment of varicose veins of the seminal vasculature using venous embolisation painful? Embolisation of varicocele is a minimally invasive procedure performed under local anaesthesia, usually an upper access. During the procedure, the patient may feel a transient mild distension or warm sensation in the scrotum associated with the administration of embolisation materials, but this does not cause pain. Following venous embolisation, moderate pain and swelling of the scrotum may occur, usually lasting up to 3-10 days after the procedure. Such symptoms respond well to painkillers and cool compresses. Compared to traditional surgery, venous embolisation is associated with less postoperative pain, faster recovery and fewer complications. Can I go to the gym while diagnosed with varicose veins? In cases of varicose veins of the spermatic cord, moderate physical activity is indicated. However, we recommend avoiding strenuous, isometric strength exercises involving the abdominal muscles and diaphragm (e.g. heavy squats, standing barbell presses, etc.), as these lead to a large increase in intra-abdominal pressure and can exacerbate venous reflux and significantly dilate the remaining veins in the pelvis and abdominal cavity. Endurance sports such as swimming or running are a good choice. It is important to wear well-fitting underwear or suspender shorts during exercise to provide adequate support for the scrotum. Can varicocele cause infertility? Varicocele is one of the most common causes of male infertility, with up to 40% infertile men, according to a recent study. They affect the congestion of the testicles and their abnormal thermoregulation, leading to overheating and poorer semen quality. Men with varicocele are found to have a reduced total sperm count, decreased sperm concentration, motility and percentage of normal forms. Causal treatment of male venous insufficiency, especially in young men, offers the opportunity to improve semen parameters and fertility. Can varicose veins of the seminal vagina make intercourse difficult and can surgery improve this? The occurrence of varicocele is usually associated with pelvic venous insufficiency and impaired venous blood outflow from the scrotal sac and penis. It is common for patients with these problems to have erectile dysfunction and to suffer from soreness during intercourse. Varicose veins that are visible to the naked eye can cause feelings of shame and embarrassment and thus have a negative impact on libido and sexual satisfaction. The surgical treatment of varicose veins leads to an improvement in the local blood supply and a cessation of discomfort, which usually also translates into a better quality of sexual life. How long does it take to recover from intravenous varicose vein treatment and when can I return to work? The time to return to full activity depends mainly on the type of treatment used. After endovascular procedures (venous embolisation) the patient returns home 2-4 hours after the procedure. At the Phlebology Clinic, we recommend 7-14 days of rest and avoiding strenuous exertion. A return to typical physical work is possible after approximately 2 weeks. Related issues 01 / Pelvic venous insufficiency in men 02 / Venous insufficiency in young adults 03 / Venous embolisation Modern vein treatment We offer treatment both on an outpatient basis and in day ward admissions. The stay is of short duration. The patient spends between 1 and 5 hours in the Clinic. Make an appointment
