Varicocele: Causes, Symptoms, and Treatment Options

The issue of varicocele?

Hello Doctor, last October I experienced left-sided varicocele, which caused a heavy, aching sensation in my entire testicle.
After going to the hospital and undergoing an ultrasound, I was diagnosed with varicocele.
In mid-November, I underwent a left-sided vascular ligation surgery.
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 was found that there was no reflux or swelling 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 worsens in the evening to the point where I can hardly walk.
Sometimes I also feel a swelling sensation in the anal area, but after sleeping, I feel much better; lying down alleviates the symptoms.
The heaviness in the left testicle is quite pronounced compared to the right side, almost as if something has dropped into it.
Currently, the left side is still frequently uncomfortable, and the right side has started to show signs of reflux and pain, but the right side does not feel as heavy and 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 pain on the left side are due to something dropping into the scrotum (since the symptoms alleviate when lying flat or inverting, indicating something is entering).
However, since the left vein has been ligated, how can blood still flow into it? The ultrasound shows no reflux.
I understand the vein is ligated above the inguinal canal; is it possible for blood to still 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 is causing swelling in the scrotum?
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 blockage in the blood vessels near the anus.
Is there a connection between varicocele and hemorrhoids?
5.
In 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 section 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, over a period of 6 months to 1 year, as the venous return is managed, the swelling will gradually subside.
This type of surgery does require time for improvement.
2.
The arterial walls are quite thick, and unless there is significant pressure, they do not easily swell.
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 adequately addressed, 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 healthcare facilities when necessary.
Best regards,
Director of Urology, Hsu Wei-Kai
Taitung Hospital, Department of Health, Executive Yuan

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 sometimes fertility issues. Understanding the causes, symptoms, and treatment options for varicocele is essential for managing this condition effectively.

Causes of Varicocele
Varicocele typically occurs when the valves in the veins that carry blood from the testicles to the heart fail to function properly. This malfunction leads to blood pooling in the veins, causing them to enlarge. The exact cause of this valve failure is not always clear, but it may be related to anatomical factors, such as the position of the left renal vein, which can create pressure on the left testicular vein. Other contributing factors may include genetics, hormonal changes, and increased pressure in the abdomen due to activities such as heavy lifting or straining.

Symptoms of Varicocele
Common symptoms of varicocele include:
1. Pain or Discomfort: Many patients report a dull ache or a feeling of heaviness in the scrotum, which may worsen after prolonged standing or physical activity.

2. Visible Veins: Enlarged veins may be visible through the skin of the scrotum, often described as a "bag of worms."
3. Testicular Atrophy: In some cases, the affected testicle may be smaller than the other due to reduced blood flow.

4. Fertility Issues: Varicocele is associated with male infertility, as it can affect sperm production and quality.

Treatment Options for Varicocele
Treatment for varicocele may not be necessary if there are no symptoms or fertility issues. However, if symptoms are present or if infertility is a concern, several treatment options are available:
1. Surgical Repair: The most common treatment is a surgical procedure called varicocelectomy, which involves tying off the affected veins to redirect blood flow. This can be done through open surgery or minimally invasive laparoscopic techniques.

2. Embolization: This is a less invasive procedure where a catheter is used to block the affected veins, causing them to shrink and redirect blood flow.

3. Pain Management: For those with mild symptoms, over-the-counter pain relievers may be sufficient to manage discomfort.

Addressing Your Concerns
1. Persistent Symptoms: It is not uncommon for patients to experience discomfort even after surgery. The sensation of heaviness or pain may persist due to nerve irritation or other factors unrelated to blood flow. If imaging shows no significant reflux or swelling, it may be worth discussing with your physician the possibility of nerve entrapment or other causes of your symptoms.

2. Blood Flow and Reflux: After a varicocelectomy, the goal is to prevent blood from pooling in the affected veins. However, if you are experiencing symptoms similar to those before surgery, it is essential to communicate this with your healthcare provider. They may consider further imaging or evaluation to rule out other issues.

3. Understanding Varicocele vs. Arterial Issues: Varicocele specifically refers to the enlargement of veins, not arteries. The anatomy of the vascular system includes arteries and veins, which serve different functions. Arteries carry oxygenated blood away from the heart, while veins return deoxygenated blood. The connection between these systems is through capillaries, and while arterial issues can occur, they present differently than varicocele.

4. Connection to Other Symptoms: The sensation of pressure or discomfort in the rectal area may be related to pelvic congestion or other vascular issues. While varicocele primarily affects the veins of the scrotum, it can sometimes be associated with pelvic venous insufficiency, which may contribute to discomfort in surrounding areas.

5. Curvature of Blood Vessels: The appearance of twisted or enlarged veins on ultrasound is characteristic of varicocele. If these veins are causing significant symptoms, your doctor may discuss the possibility of further intervention, but this decision should be based on a comprehensive evaluation of your symptoms and imaging results.

Conclusion
Managing varicocele involves understanding the condition, its symptoms, and the available treatment options. If you continue to experience discomfort after surgery, it is crucial to maintain open communication with your healthcare provider to explore further diagnostic and treatment options. Varicocele can be a complex condition, and addressing your concerns with a specialist can help you find relief and improve your quality of life.

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