Varicose veins of the scrotum
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Scrotal varicose veins, referred to in medicine as varicoceles (Latin: varicocele), are a pathological dilation of the pampiniform plexus of veins surrounding the spermatic cord. This condition results from incompetence of the venous valves or disturbances in venous outflow from the testes, which leads to blood stasis and dilation of the venous vessels within the scrotum. Varicoceles occur in about 10–20% of men, most often on the left side, due to the specific anatomical conditions of venous drainage from the left testicular vein. In some patients they are asymptomatic, but they can cause discomfort, pain, and affect fertility by worsening semen parameters.
Varicose veins of the scrotum – causes
The main cause of varicocele formation is a disturbance of the normal venous drainage from the testes, resulting from incompetence of the venous valves within the testicular (gonadal) vein. These valves, under normal conditions, prevent the backflow of blood under the influence of gravity. When their function is impaired, venous reflux occurs, i.e., the backflow and pooling of blood in the venous vessels of the pampiniform plexus.
The most important factors favoring the development of varicoceles include:
- anatomical predispositions, particularly on the left side – the left testicular (gonadal) vein drains into the renal vein at a right angle, which promotes increased venous pressure
- venous valve incompetence, leading to backflow of blood
- increased intra-abdominal pressure, e.g., with chronic cough, constipation, or intense physical exertion
- prolonged standing or sitting, which impairs proper venous return
- compression of the renal vein (the so-called nutcracker syndrome), in which the left renal vein is compressed between the aorta and the superior mesenteric artery.
Less often, varicoceles may be secondary to other diseases, such as tumors of the abdominal or retroperitoneal space compressing the venous vessels. For this reason, the sudden appearance of varicoceles, especially on the right side or at an older age, requires thorough diagnostic evaluation.
Scrotal varicose veins – symptoms
In many cases scrotal varicoceles are asymptomatic and are discovered incidentally during a physical examination or infertility evaluation. In some patients, however, symptoms occur related to chronic blood stasis within the pampiniform plexus.
The most common symptoms include:
- a feeling of heaviness in the scrotum, worsening with prolonged standing or physical exertion
- dull pain in the testicle or scrotum, which usually subsides when lying down
- visible or palpable dilated veins, often described as "bag-like" or resembling a "bag of worms"
- scrotal asymmetry, especially with larger varicoceles
- reduced semen quality, which may lead to fertility problems
On physical examination the physician may note dilated, tortuous venous vessels above the testicle, which become more noticeable during a Valsalva maneuver (straining the abdominal muscles). Doppler ultrasound examination is also used in diagnostics, allowing assessment of blood flow in the testicular veins and the degree of reflux.
An important clinical aspect is the effect of varicoceles on testicular function. Blood stasis leads to increased temperature in the scrotal area, oxidative stress and microcirculatory disturbances, which can impair spermatogenesis (the process of sperm production).
Scrotal varicose veins – treatment
Treatment of scrotal varicoceles depends on the severity of symptoms, the patient’s age and the impact of the disease on fertility. In asymptomatic cases, especially when semen parameters are normal, often only observation and follow-up examinations are performed.
Indications for treatment most often include:
- chronic pain or discomfort in the scrotum
- worsening of semen parameters
- male infertility related to varicoceles of the spermatic cord
- arrested testicular growth in adolescents.
The most commonly used method of treatment is surgical treatment, consisting of ligation or closure of incompetent veins. The main techniques include:
- microsurgical varicocelectomy – considered one of the most effective methods; it is performed using an operating microscope, which allows precise closure of the dilated veins while preserving arterial structures and lymphatic vessels
- laparoscopic ligation of the testicular (spermatic) vein, performed through small incisions in the abdominal wall
- percutaneous embolization, i.e., closure of the testicular (spermatic) vein using embolic materials introduced through a catheter into the vascular system.
The aim of treatment is to restore normal venous drainage from the testis, reduce scrotal temperature and improve spermatogenesis. In many cases after treatment an improvement in semen parameters is observed, although this effect depends on the stage of the disease and the patient’s age.
It should be emphasized that scrotal varicoceles are a relatively common condition and in most cases have a benign course, however their impact on fertility means they require appropriate urological diagnostics and – when indicated – appropriate treatment.
