Varicocele: Symptoms, Treatment, and Related Concerns

The issue of varicocele?

Hello Doctor, last October I experienced left-sided varicocele, which caused a feeling of heaviness and pain in my entire testicle.
After going to the hospital and having an ultrasound, I was diagnosed with varicocele.
I underwent a left-sided vein ligation surgery in mid-November.
My attending physician informed me that the veins would gradually shrink.
However, it has now been four months, and I still feel uncomfortable.
I returned to see my attending physician, and after a follow-up ultrasound, it showed no reflux or edema on the left side, yet I still feel discomfort.
The symptoms seem similar to before the surgery; after walking for a while or sitting for too long, I experience a feeling of heaviness and soreness, which intensifies in the evening, making it almost impossible to walk.
Sometimes I also feel a swelling sensation around the anus, but after sleeping, I feel much better; lying down alleviates the symptoms.
The heaviness in my left testicle is significantly more pronounced compared to the right side, almost as if something has dropped inside.
Currently, the left side remains frequently uncomfortable, and the right side has started to show signs of reflux and pain, but there is no heaviness on the right side and it is less painful.
I am unable to work throughout the day.
I would like to ask if there are any treatment options available.
Additionally, I have a few questions:
1.
I feel that the heaviness and swelling on the left side are due to something dropping into the scrotum (because the symptoms alleviate when lying flat or inverting, indicating something is inside).
However, since the left vein has been ligated, how can blood still flow in? The ultrasound shows no reflux.
I understand that the vein is ligated above the inguinal canal; is there still a chance that blood could flow into the damaged segment of the vein, causing continued swelling and pain?
2.
If there is no reflux after the vein ligation, could it be that something else has entered the scrotum causing the swelling?
3.
Why is there no arterial varicocele, only venous varicocele? Are arteries and veins directly connected, or is there connective tissue in between? Is there a possibility for dilation in the arteries, connective tissue, or microvessels, or is it solely related to the varicocele?
4.
Are the blood vessels in the testicles not connected to surrounding organs such as the penis and anus? I do feel a swelling sensation on the left side of the anus when the testicle feels heavy, almost like a feeling of blood congestion in the vessels near the anus.
Is there a connection between varicocele and hemorrhoids?
5.
On the ultrasound, I can see that the blood vessels near the lower part of my left testicle are twisted together.
Would it be necessary to ligate this twisted segment for improvement? Thank you, Doctor.

Remix, 40~49 year old female. Ask Date: 2012/03/19

Dr. Xu Weikai reply Urology

Hello,
1.
The swelling and discomfort in the scrotum are likely due to continuous arterial blood flow.
The surgery primarily addresses the venous return.
In the short term, because the arteries continue to supply blood to the scrotum, there may indeed be swelling, which could be even more pronounced than before the surgery.
However, after 6 months to 1 year, as there is no venous return, the swelling will gradually subside.
This type of surgery does require time for improvement.
2.
The arterial walls are quite thick, and unless the pressure is sufficiently high, swelling is not easily induced.
3.
There are connections between the neurovascular structures to some extent.
4.
There is no need for additional procedures; as long as the venous return is properly managed, this area will gradually atrophy.
If there are any unclear points, feel free to ask again for further discussion and research.
Online responses should only serve as a reference; it is essential to seek medical attention at a healthcare facility if necessary.
Sincerely,
Dr.
Hsu Wei-Kai,
Department of Urology, Taitung Hospital, Ministry of Health and Welfare

Reply Date: 2012/03/19

More Info

Varicocele is a condition characterized by the enlargement of veins within the scrotum, similar to varicose veins that can occur in the legs. It is often associated with discomfort, pain, and can potentially affect fertility. Your symptoms and experiences following the surgical intervention for left-sided varicocele are not uncommon, and I will address your concerns systematically.

1. Persistent Symptoms Post-Surgery: It is not unusual for patients to continue experiencing discomfort after varicocele surgery, even if imaging studies show no significant complications such as reflux or swelling. The sensation of heaviness or discomfort can persist due to nerve irritation, inflammation, or changes in the surrounding tissue post-surgery. The fact that your symptoms improve when lying down suggests that gravity plays a role in your discomfort, which is typical in varicocele cases.

2. Blood Flow and Reflux: After surgical intervention, the goal is to prevent blood from pooling in the affected veins. However, if there are collateral veins or if the surgical site does not completely obstruct blood flow, some blood may still reach the affected area. This could lead to continued symptoms even if ultrasound does not show significant reflux. The body can develop alternative pathways for blood flow, which might not be visible on imaging.

3. Other Causes of Symptoms: If the veins have been surgically interrupted, other conditions could be contributing to your symptoms. For instance, conditions like epididymitis or other forms of inflammation in the scrotal area could mimic varicocele symptoms. It’s essential to rule out these possibilities through further evaluation.

4. Understanding Varicocele vs. Arterial Conditions: Varicocele specifically involves the veins of the spermatic cord. The arteries supplying blood to the testicles (testicular arteries) are not typically involved in varicocele formation. The anatomy of the vascular system means that veins can become dilated due to increased pressure, while arteries generally do not exhibit similar conditions due to their structure and function. The connection between arteries and veins is through capillary networks, and the dilation of veins does not directly affect arterial flow.

5. Connection Between Testicular and Rectal Symptoms: The sensation of discomfort in the rectal area when experiencing testicular pain could be related to shared nerve pathways. The pelvic region is densely innervated, and pain can often be referred from one area to another. While varicocele and hemorrhoids (痔瘡) are separate conditions, they can coexist due to increased venous pressure in the pelvic region.
6. Ultrasound Findings: The presence of twisted or convoluted veins near the testicle may indicate ongoing venous congestion or inadequate drainage. If these veins are causing significant symptoms, further intervention may be warranted. Discussing the possibility of additional surgical options with your urologist or a specialist in male reproductive health could be beneficial.

In conclusion, your ongoing discomfort after varicocele surgery is a complex issue that may involve multiple factors, including nerve irritation, collateral blood flow, or other unrelated conditions. It is crucial to maintain open communication with your healthcare provider, who may recommend further imaging or alternative treatments based on your symptoms. Additionally, consider consulting a specialist in male reproductive health or a urologist with experience in post-surgical complications to explore your options for relief.

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