"So, doc, it looks like I've got a bag of worms in my scrotum."
File that among phrases no one ever wants to utter to a medical professional.
It's right up there with, "I thought the fuse was longer."
Varicoceles won't cause the loss of any digits, but the condition does present with a squiggly snarl of puffy veins just above a testicle. They're often harmless, despite their weird appearance, but varicoceles can pose specific problems that require medical intervention, so you should know a few facts if your scrotum starts looking like it would fit in at a bait shop.
What is a varicocele?
If you've ever seen varicose veins—the kind people get in their legs—you have a pretty good idea of how varicoceles appear: The veins above one or both testicles become enlarged.
Symptoms can include the following:
- Testicle discomfort, ranging from a dull ache to a sharp pain
- Pain that increases with physical exertion, especially lifting
- Pain that gets worse throughout the day
- A noticeable relief in pain after lying down
- Testicular atrophy
- Fertility issues
Varicoceles and fertility
The last symptom will undoubtedly get your attention, but not all men who have varicoceles have trouble conceiving. However, 40 percent of men tested for fertility problems have a varicocele, according to the American Urological Association. For men who've already fathered a child, the number is even higher.
"Varicoceles are the most common cause of secondary infertility," said Neel Parekh, M.D., a urologist who specializes in fertility with the Cleveland Clinic. "Primary infertility is for men who have never fathered a child. Secondary infertility is men who have had a child previously, but now are struggling to conceive their second child. In about 80 percent of [secondary infertility] cases, it can be related to a varicocele."
'When you have a varicocele, you basically have those veins full of venous blood, and that increases the temperature of the testicle, which doesn't make it a good environment for sperm production.'
The exact nature of the link between varicoceles and infertility remains a subject of debate in the medical community. One hypothesis includes body temperature.
"There's a number of theories as to why this occurs," Parekh said. "The leading theory is the testicles sit in the scrotum, so they can be 2 or 3 degrees cooler than the core body temperature. But when you have a varicocele, you basically have those veins full of venous blood, and that increases the temperature of the testicle, which doesn't make it a good environment for sperm production."
Testicular atrophy and varicoceles
Aside from fertility concerns, another reason to seek medical care when dealing with varicoceles is that they can lead to testicular atrophy during childhood development.
Occasionally, the altered blood flow to the affected testicle can cause it to develop more slowly than its counterpart, prompting an intervention before the effect becomes too pronounced.
"It's particularly an issue with adolescents," said Richard Heppe, M.D., a Denver-based urologist whose practice is affiliated with the Urology Center of Colorado. "In a small number, it can lead to testicular atrophy, where the testicle on the affected side doesn't grow as rapidly as the one on the unaffected side."
Which side are you on?
Another consideration is whether a varicocele is on the left or right side of the scrotum. Due to the way blood circulates to the testicles and drains from them, up to 90 percent of varicoceles appear on the left side. Sometimes they occur bilaterally, on both sides of the scrotum, and rarely, they appear solely on the right side—a development once considered alarming.
"In the past, there was a big concern that if a right-side varicocele was noted, there was a concern for some sort of mass, tumor or blockage," Parekh said. "It was recommended to do some sort of imaging, either a CAT scan or ultrasound, looking at the kidney or the lymph nodes to make sure there was no tumor. It's still not unusual to order that sort of test when we see a patient with that scenario. But there is also some data to show that it's pretty rare to find something like that."
When a varicocele becomes too painful, is thought to be interfering with sperm production or is causing testicular atrophy, a patient has few options but medical intervention.
"These are just varicose veins in the spermatic cord, so it's not something you can just take medication to correct," Heppe said. "You need either surgery, or you go in and tie off the affected vein, or a radiologist can pass a catheter through the veins, starting in the femoral vena cava."
Another option is microsurgery. As a fertility specialist who did a fellowship in microsurgery, Parekh frequently gets called upon to repair varicoceles.
"I did a couple of microscopic varicocelectomies yesterday," Parekh said recently. "The method that's been shown to have the least number of complications and the least chance of [them] coming back is the microscopic technique."
Varicoceles and testosterone
Some recent studies point to a possible link between varicoceles and low testosterone, and the possible benefits of varicocele repair for low-T. Given the known negative effects of varicoceles on the primary function of the testicles—producing sperm—it's not insupportable to suggest testosterone production could be affected.
However, urologists are quick to note there isn't sufficient evidence to point to a definitive link.
"There is some data to support that connection [between varicoceles and low-T]," Parekh said. "It's not enough data yet to where it's in the guidelines. So it's not in the American Urologic guidelines—it's not an indication to treat varicoceles. It's something I come across, but I counsel patients that there's just not enough data yet."
Varicoceles are common, and while many men may not even notice them, others experience acute pain, fertility issues or other testicular problems.
If the veins above your testicles are starting to look a little wormy, don't hesitate to see your healthcare provider.