By Dr. Alexander W. Pastuszak, a resident physician at Baylor College of Medicine
Have you ever felt your scrotum and found it to have soft lumps in it? If so, you might have a varicocele, which literally means “tumor of the veins,” and is caused by dilation of the veins that drain your testicle. Don’t worry, a varicocele is not even remotely related to cancer, but over time it may negatively impact your fertility and your testicle’s ability to produce sex hormones. In fact, from a fertility standpoint, 15% of men with fertility problems have a varicocele, and it’s the most common treatable condition associated with male fertility problems, though it’s not always the cause of these issues.
How do you diagnose a varicocele? Usually your doctor will start with a scrotal exam, which can help determine whether the veins in the scrotum are swollen on one or both sides. There are several grades of varicocele, and only the highest – grade 3 – is visible without feeling the veins directly. A varicocele frequently does not cause discomfort, so these are most commonly identified in men with fertility issues or adolescent boys who notice a “bag of worms,” which incidentally is usually a grade 3 varicocele. If your doctor finds evidence of a varicocele, he or she may recommend an ultrasound to measure the size of the veins in the scrotum and the blood flow in them. If your veins are more than 3mm in diameter and if the blood flow in those veins reverses while you are doing a Valsalva maneuver, then you have a varicocele.
What causes varicoceles? We’re not entirely sure, but it appears that the blood flow through the spermatic cord veins may be blocked higher up, or the valves in the veins don’t close very well and thus permit backflow of blood. Of note, 90% of varicoceles are on the left side, perhaps because of the anatomic factors described above.
Let’s say you are diagnosed with a varicocele – should you be worried? As I mentioned above, having a varicocele can affect a man’s fertility by decreasing the number of sperm and their ability to move. This is thought to be in part because the backed up blood increases the temperature of the testicle, which decreases its ability to produce sperm. Understand, however, that fewer sperm may not necessarily impact your ability to have children, as it takes only one sperm, of the millions that are typically ejaculated, to fertilize an egg, and both the man and the woman need to be considered when thinking about how “fertile” a couple is. However, having a varicocele can also affect the testicles’ ability to produce necessary hormones such as testosterone. In fact, a recent study demonstrated that men with a varicocele have lower testosterone levels than those without one, and that fixing the varicocele may result in an increase in testosterone levels. Therefore, in younger men and adolescents, it may be a good idea to at least keep an eye on the varicocele over time, if not fix it right away.
If you have a varicocele, then, what should you do about it? Based on the available data, if you’re an adolescent boy, then fixing the varicocele is probably the way to go, particularly because of the potentially increased risk of low testosterone as you get older. However, this decision is ultimately up to you and your doctor, and the data do show that testosterone levels may increase back to normal after your varicocele is fixed, indicating that you would likely have some time to make your decision regarding treatment if you chose to observe the varicocele. From a fertility standpoint, it remains unclear just how much more “fertile” a man becomes after his varicocele is fixed. Yes, there are more sperm, they look better, and they swim better after a varicocele is fixed, but whether this actually translates into a more fertile man is unclear. Nevertheless, if there’s no other reason for a couple’s fertility difficulties and the man has a varicocele, then your doctor may recommend repair. Regarding repair – there are many options, which I’ll detail in a future blog.
So, the main take home points here are: 1) if you’ve got a lumpy, soft scrotum, it may be a varicocele and, depending on where you are in life, you should get it checked out; 2) not all varicoceles need to be fixed, though if you’re younger and the varicocele is more severe, then you and your doctor should talk about repair.