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Varicocele

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What is Varicocele?

Varicocele refers to an enlargement of the veins within the scrotum, the loose bag of skin that holds the testicles. These enlarged veins are known as the pampiniform plexus. Varicoceles are similar to varicose veins, which are commonly found in the legs. 

This condition typically develops during puberty and can grow larger or become more noticeable over time. Varicoceles are more prevalent on the left side of the scrotum due to the anatomical differences in male venous circulation. While varicoceles are mostly harmless, they can sometimes cause discomfort and pain, or lead to infertility issues.

Grading a Varicocele

Varicoceles are graded based on their size and physical examination findings. This grading helps in diagnosing the severity of varicoceles and can guide treatment decisions.

Grade 1

The smallest type of varicocele, only detectable by ultrasound or through a Valsalva manoeuvre (a technique involving a deep breath and bearing down) during physical examination.

Grade 2

Moderately sized, palpable or felt with the hand during examination, but not visible to the eye.

Grade 3

The largest and most noticeable type of varicocele. These are visibly enlarged veins that are seen and felt in the scrotum.

Causes and Risk Factors

Varicoceles appear to be a condition that can occur in any male, regardless of lifestyle, health status, or other conditions. Though the precise cause is not fully understood, several factors may play a role in the development of the condition.

  • Valve Dysfunction in Veins: One of the primary speculated causes is the malfunction of valves within the veins of the scrotum. These valves prevent the backflow of blood. When they fail to function correctly, blood can pool in the veins, leading to their enlargement and the formation of varicoceles.
  • Anatomical Differences: The male reproductive anatomy, particularly the venous drainage system, differs on the left and right sides. These differences can contribute to varicoceles, which are more commonly found on the left side.
  • Secondary Causes: In rare cases, varicoceles can be caused by other factors such as blockages from swollen lymph nodes or masses that impede normal blood flow. This can lead to sudden and often painful swelling of the veins in the scrotum.
  • Age Factor: Varicoceles typically develop during puberty and can become more pronounced or noticeable over time. There is no specific age group that is exempt from this condition, highlighting its unpredictable nature.

Symptoms and Signs

Varicoceles often do not cause any symptoms and are usually harmless. When symptoms do occur, they can include:

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    Pain and Discomfort

    The pain associated with varicoceles is typically described as a dull, aching sensation. It can vary in intensity, often worsening with prolonged standing or physical exertion and improving when lying down. The discomfort might also increase as the day progresses.

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    Scrotal Changes

    A varicocele can cause noticeable changes in the scrotum. This includes swelling or a mass that resembles a "bag of worms", particularly noticeable when standing. The enlarged veins responsible for this sensation are due to the pooling of blood.

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    Testicular Size Discrepancy

    Varicoceles can affect the size and development of the testicles. The testicle on the side of the varicocele may be smaller than the other.

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    Fertility Concerns

    While not all varicoceles cause infertility, they can be a factor in reduced sperm production and quality. This may lead to difficulties in fathering a child.

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    Other Symptoms

    Some men may also experience a sensation of heaviness or dragging in the scrotum. In severe cases, the varicocele can cause atrophy or shrinkage of the testicular tissue.

Diagnosis

Diagnosing varicoceles combines both physical examination techniques and imaging tools to ensure an accurate diagnosis, particularly in cases where the varicocele is not immediately apparent or where fertility issues are involved.

  • Physical Examination: A doctor can detect a varicocele by inspecting and feeling the scrotum, both while the patient is lying down and standing. The Valsalva manoeuvre, where the patient takes a deep breath, holds it and bears it down, can make a varicocele more prominent and easier to identify.
  • Ultrasound Imaging: An ultrasound creates images of the scrotum’s internal structures, helping to assess the size of the veins and detect any abnormalities. It is useful for identifying smaller varicoceles that might not be palpable.
  • Assessing Fertility Impact: In cases where fertility is a concern, additional tests, such as semen analysis, might be conducted. This can help determine if the varicocele is affecting sperm production or quality.

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Treatment Options

Each treatment option comes with its own set of considerations, and the choice largely depends on the individual’s symptoms, fertility goals, and overall health.

Observation

Many varicoceles do not require treatment and can be managed through regular monitoring, especially if they are asymptomatic and do not affect fertility.

Surgery

Surgical intervention is considered when varicoceles cause pain, testicular atrophy, or fertility issues. Common surgical procedures include:

  • Microscopic Varicocelectomy: This involves a small incision and the use of a microscope to ligate the enlarged veins.
  • Laparoscopic Varicocelectomy: A minimally invasive procedure where small incisions are made in the abdomen, and surgical tools are used to ligate the veins.

Embolization

A non-surgical option where a radiologist uses coils or sclerosant to block the blood flow to the varicocele. This procedure is generally less invasive than surgery and has a shorter recovery time.

Pain Management

For minor discomfort, over-the-counter pain medications like acetaminophen or ibuprofen can be effective.

Lifestyle Modifications

Wearing supportive undergarments, such as athletic supporters, can help alleviate discomfort.

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Dr Lee Fang Jann image

Dr Lee is a urologist and kidney transplant surgeon with a broad-based expertise of all urological disorders

He has subspecialty focus on men’s health and male infertility, and special interest in minimally invasive prostate enlargement therapy and kidney stone treatment. Dr Lee has received numerous awards for service excellence such as the Service With A Heart Award (2006-2008, 2011) and the Singapore Health Quality Service Award (2016).

  • Bachelor of Medicine and Bachelor of Surgery (Singapore)
  • Membership of The Royal College of Surgeons (Edin)
  • Master of Medicine (Surgery) (Singapore)
  • Fellowship of the Academy of Medicine (Urology)
  • Clinical fellowship at Oxford Transplant Centre in the UK

Prior to entering private practice, Dr Lee served in the public sector for 16 years at SGH, where he initiated dedicated clinics evaluating and treating patients with complex men’s health and fertility issues. He also led the Renal Transplant Program and laparoscopic donor nephrectomy service as Surgical Director.

Apart from clinical work, Dr Lee is active in academia and believes in the importance of grooming the next generation of doctor. He was Senior Clinical Lecturer at NUS’ Yong Loo Lin School of Medicine and currently, Adjunct Assistant Professor at the Duke-NUS Medical School. Dr Lee is also regularly invited to share his experiences locally and regionally through lectures, workshops and surgical demonstrations.

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    Frequently Asked Questions (FAQ)

    What is a varicocele?
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    A varicocele is an enlargement of the veins within the scrotum, similar to varicose veins that can occur in the leg.

    How common are varicoceles?
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    Varicoceles are common, affecting about 10 to 15 out of every 100 males. It is often noticed during puberty.

    Can varicoceles lead to infertility?
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    While not all varicoceles affect fertility, they can be a factor in decreased sperm production and quality, leading to fertility issues in some men.

    How are varicoceles diagnosed?
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    They are often diagnosed through physical examination and sometimes assisted by ultrasound, especially when physical symptoms are not prominent.

    What are the treatment options for varicoceles?
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    Treatment options include watchful waiting for asymptomatic cases, surgery, and embolization. The choice of treatment depends on the severity of symptoms and any associated fertility issues.

    Is surgery always necessary for varicoceles?
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    Surgery is not always necessary, especially if the varicocele is not causing symptoms. Treatment is usually considered when there is pain, testicular growth issues, or infertility.

    What can be expected after varicocele treatment?
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    Post-treatment recovery generally involves mild discomfort with a quick return to normal activities. Fertility improvements, if relevant, are usually assessed a few months post-treatment.