Prof. Dr. Ates Kadıoglu

Submitted by hasan on Wed, 03/23/2022 - 12:29

It is a clinical condition that occurs with the enlargement of the veins around the testicles. A varicocele is similar to a varicose vein you might see in your leg. It is the most common correctable cause of male infertility.

The exact cause of varicocele is unknown. The fact that varicocele mostly occurs during adolescence and is rarely seen under the age of 10 has brought to mind the idea that it may be associated with the rapid growth of the genitals. However, it is more common in patients with increased intra-abdominal pressure such as obesity and in people with occupations that require standing work (teacher, police), which has shown that many factors are effective in the development of varicocele. There are valves inside the veins that control the flow of blood towards the lungs. Another theory in the development of varicocele is the idea that these valves fail to prevent the blood from flowing backwards and that the blood accumulates backwards and causes enlargement in the veins.

Studies have shown that 15% of men in the general population and 19-41% of men presenting with infertility complaints have varicocele. Varicocele is seen at a rate of 80% in men who had children before and could not have children again when they wanted to. Varicocele is usually more common on the left side than on the right. While the rate of single left varicocele is 90% and bilateral is 9-10%, the rate of right varicocele alone is only 1-2%.

Although the answer to this question is not known for sure, some factors are thought to be effective:

  • The testicle on the left is lower than the one on the right
  • The relationship of the left testicular vein with the organs in the abdomen and its course is longer and different
  • Different way of connecting the left testicular vein to the main vein.

Varicocele usually does not give any symptoms, but is diagnosed during the doctor's examination of patients who apply with the complaint of infertility. Patients with varicocele; they may apply wirh complaints of

  • Infertility
  • Testicular pain
  • Irregular worm-like varicose veins around the testicles
  • Softening in testicular consistency and reduction in size.

There is no definite information yet about why varicocele causes infertility in some men. However, due to varicocele, it is thought that due to the low oxygen level accumulating towards the testis, the blood containing dense residues cannot be removed from the testicles and increased the temperature in the testis, resulting in decreased sperm production and affecting the shape, movement and function of sperm cells.

Diagnosing varicocele is relatively simple. Careful people may suspect the worm-like irregularity and swelling on the testicle during self-examination and consult a doctor to see if there is varicocele, but varicocele is mostly diagnosed during the physical examination performed by the doctor in patients presenting with complaints of infertility. Varicocele examination; It is done by observing the genital area while the patient stands upright and repeats movements that increase intra-abdominal pressure (coughing, straining) with the doctor's directive. Varicocele is graded according to the findings detected during the observation:

  • Grade 1 varicocele: Varicocele that can only be detected manually during movements that increase the pressure for the abdomen
  • Grade 2 varicocele: Varicocele, in which the veins become clearly visible only during movements that increase intra-abdominal pressure
  • Grade 3 varicocele: Varicocele in which the veins are clearly visible even though it does not make movements that increase intra-abdominal pressure

There is no need for additional imaging methods other than physical examination in the diagnosis of varicocele. However, in cases that complicate the examination, for example, in patients with testes above the scrotum, in patients with physical characteristics (obesity, hydrocele, testicular tenderness) that make the examination difficult, Doppler ultrasonography for the testicles can be performed for diagnosis.

We can divide patients with varicocele requiring treatment into two groups:

  • Varicocele patients presenting in adolescence: The incidence of varicocele in adolescence is 11%. In this period, approximately 10% of the patients experience reduction in testicular size and softening of the testicular consistency due to varicocele. Today, reduction of testicular size by more than 10% on the side with varicocele or a difference of more than 20% between the two testicular volumes is the most accepted treatment indication in adolescence. If the testicles are of equal and normal consistency at the time of diagnosis, it is sufficient to follow up the patients with a physical examination and measurement of testicular volumes once a year.
  • Varicocele patients presenting in adulthood: Men who apply with the complaint of infertility, who do not have any other disease other than varicocele to explain this condition, who have low one or more parameters (sperm count, concentration and sperm motility) in at least two semen analysis and who have varicocele that can be detected in physical examination are suitable patients for treatment. are candidates. However, despite previous varicocele surgery, infertility complaints continue,a decrease in one or more parameters in the semen analysis performed at least twice, during maneuvers that increase intra-abdominal pressure, patients with veins larger than 3 mm in the testicular Doppler ultrasonography and in which blood reflux is observed should also be treated surgically.

Testicular pain improves 48-90% after surgery. Due to the wide range in success rates, there is no consensus on the treatment of patients who apply only with testicular pain, but it is accepted that it can be recommended with accurate patient information. There is no treatment indication for varicocele (subclinical varicocele), which is admitted with the complaint of infertility, semen parameters are normal, cannot be detected in physical examination, but detected in testicular Doppler ultrasonography.

Treatment is not recommended for every patient diagnosed with varicocele. In order to successfully treat the right patient, it is very important to distinguish between varicocele patients that require treatment and those that do not, by evaluating patient age, complaints at admission, physical examination findings and patient expectations. The most effective solution in the treatment of varicocele is microscopic surgery. After the right patient selection; The surgery is performed by ligating and cutting the varicose veins through the incision made in the inguinal region using 8-10 times magnification under the microscope. In experienced hands, recurrence and complication rates (hydrocele, testicular atrophy) are very low after surgeries performed by preserving testicular arteries and lymphatic vessels. However, recurrence and complication rates are higher in surgeries performed without using a microscope or in non-surgical treatment methods, so the success rates may be relatively lower.

For this reason, the application of microscopic surgical methods in the treatment of varicocele is recommended by the European Association of Urology. Prof. Dr. Ateş Kadıoğlu, in addition to his high success and patient satisfaction with his experience in thousands of diseases in microscopic varicocele surgery, also makes important contributions as an author to the "Varicocele Treatment Guide" published every year by international professional organizations.

After surgical treatment, patients usually stay in the hospital for one day and are called for control 7-10 days later. Patients are advised to abstain from sexual intercourse for four weeks and from heavy physical activities for 3 months. It is recommended that patients have semen analysis at the third month after varicocele surgery. After varicocele surgery performed in experienced hands, an improvement of 60-80% is observed in semen parameters and successful pregnancy is achieved at a rate of 40-60%.