 Welcome to this educational program. This module discusses varicose seals. What they are, when they are important, how to recognize them, when to treat them, and how they can be treated. Please feel free to view this presentation as many times as necessary. You may also use the player on your left to repeat slides or to skip through them in any order you wish. A varicose seal is a collection of dilated veins that drain one or both testicles. They are similar to varicose veins seen commonly in the legs just in a different location. In some men, these dilated veins may not be noticeable, but in others they give the classic appearance referred to as a bag of worms in the scrotum. The collection of veins that dilates to form a varicose seal is called the Pampiniform plexus. This network of veins arises from the testicle, or testis, and follows the spermatic artery out of the scrotum, which is the sac containing the testicles. It then drains into the groin, technically the inguinal canal, and eventually into the abdominal cavity, where they unite into a single large vein called the testicular or gonadal vein. This vein drains into the large veins of the abdomen, the renal vein on the left, and the largest vein in the body called the inferior vena cava, or IVC, on the right. Note that the right testicular vein enters the inferior vena cava at more of an acute angle than the left side enters into the renal vein. Dilated veins result from back pressure in the testicular vein, which produces dilatation and poor flow through the network of veins draining the testicle. A number of different theories can account for this phenomenon, but since it usually results in the left side, most feel it is the result of the geometry between the left testicular vein and left renal vein. The left testicular vein enters the renal vein at a right angle compared to the right testicular vein, which enters the inferior vena cava at a sharper angle, thus creating more potential for backflow down the vein on the left side. Furthermore, the left testicular vein connects to the left renal vein higher in the body than the right testicular vein enters the vena cava, meaning there is a greater column of fluid and pressure due to gravity on the left side. Another theory relates to the valves that veins in the body normally have to prevent backflow as the blood flows upward against gravity. It is felt by some that these valves in the testicular veins do not function properly, allowing more blood to put back pressure on them. Most likely, different mechanisms combine their effects in different proportions in different people. Varicoseals usually begin during adolescence, between 10 and 19 years of age. Overall, they affect about 15% of young adult males. Most varicoseals affect the left side, but up to 50% may be bilateral, meaning they are found on both the left and right sides. The finding of a varicoseal on the right side only is extremely rare and requires careful investigation, as these cases may be caused by a tumor or other blockage of veins on that side. These percentages may be an underestimate since varicoseals usually cause no symptoms and are likely underreported. Varicoseals can stunt the growth of the testicles, and they can have an association with male fertility problems, meaning they can impair normal sperm function and interfere with a man's ability to father children. Approximately 50% of men investigated for male infertility have varicoseals, compared to 15% in the general population. Most researchers believe that this is because varicoseals can damage the testicles due to overheating. Testicles normally are about 2 degrees cooler than the rest of the body, and this temperature difference is essential for sperm production. A varicoseal on one side can have effects on both testicles. Correcting or repairing varicoseals can improve semen quality, fertility, and the growth of the testicles. Varicoseals can also be an uncommon cause of pain in the testicles. Because pain is such a complex process and the source of it is difficult to localize, in these situations repair of the varicoseal unfortunately does not always relieve the perceived pain. Usually, varicoseals are not associated with any symptoms, in other words, they go unnoticed. When they become large enough, they are detected as a painless, scrotal mass, classically described as a bag of worms. Men may discover them when they begin performing self-testicular examinations for testicular cancer. Often, they are discovered during a routine examination by a doctor. When diagnosing a varicoseal, your doctor will first perform a detailed medical interview followed by a physical examination. For a proper physical exam, a warm room is needed. The patient is examined both standing and lying down, with and without abdominal straining. This allows the doctor to grade the severity of the varicoseal. When present, the doctor will feel a painless, compressible mass above the testicle. While there are no special tests that can replace a good medical history and physical exam, a well-done ultrasound in the standing position can sometimes confirm the diagnosis. Ultrasound involves passing a device called a transducer over the scrotum and examining its contents using sound waves. This figure shows how varicoseals can be graded by severity. Grade 1 is a small mass that can be felt only present during a valsalva maneuver, where a deep breath is taken and held and pushed downwards to increase abdominal pressure. Grade 2 is a moderate-sized mass that can be felt without this straining maneuver. Grade 3 is a large mass visible through the skin of the scrotal sac. Because varicoseals can stunt the growth of developing testicles, part of the physical examination involves an assessment of the size or volume of the testicles. While some doctors may gauge this by experience, it is most accurately done using a standard measuring device such as a prater or disk or pedometer. A prater or pedometer is illustrated here. Varicoseals are very common, and many men will never experience any adverse effects of them. For this reason, surgical correction is not always necessary. When varicoseals are found during adolescence, surgical correction should be considered if there is reduced testicular size on the side of the varicoseal. The cutoff commonly used to determine the need for surgery is when there is a greater than 20% reduction in testicular volume compared to the other side. In adults, surgery is most commonly considered as an option to improve fertility. In other words, if there is an otherwise unexplained fertility problem and semen abnormalities in combination with a varicoseal, then surgery is recommended. Testicular pain, which typically is described as a dragging ache, particularly late in the day or after prolonged standing, is a less common reason to treat with surgery. In the absence of these preceding indications, then observation is the best solution. When treatment is required, then one has several choices, including open or laparoscopic surgery where the dilated veins are tied off or a procedure performed by a radiologist called percutaneous occlusion where the veins are blocked off with special material. Each of these will be described in more detail on the next several slides. Most of these techniques have similar effectiveness and most are done as outpatient procedures, meaning that no overnight hospital stay is required. The choice of technique will depend on its availability, your surgeon's training, and the specifics of your particular situation. Open surgery means that an incision or cut is made in the skin. As mentioned, this is usually an outpatient procedure and takes about 20 to 30 minutes. It is performed by a specialized surgeon called a urologist. It is usually but not always done under general anesthesia, meaning that you are put to sleep for it by a doctor called an anesthesiologist. In some cases, doctors may prefer to do the procedure under local anesthesia or freezing only or with spinal anesthesia where you are frozen from the waist down with a needle in the back. Regardless of which procedure you will undergo, the following recommendations are made. Do not eat or drink anything for 12 hours prior to surgery, usually nothing after midnight the night before. Do not take any products containing aspirin or ASA for five days prior to surgery as this can increase the chance of bleeding afterwards. And your doctor or hospital will instruct you in more detail if other preparations or precautions are required. In the case of an open varicoseal repair, the incision in the skin is very small, usually about three centimeters or even less, and it is usually made in the lower part of the groin as shown here. After the incision is made, the cord of structures containing the blood supply to the testicles, the testicular artery, the dilated veins draining the testicles, and the sperm duct, called the vas deferens, is isolated and exposed. The veins are carefully dissected away from the other structures, then tied off and cut. Some surgeons prefer to do this operation with the assistance of a surgical microscope, and this is called microsurgery. This provides magnification for the surgeon and improves his or her view of the tiny structures being operated on. The proposed advantages of this technique are to reduce the chance of injury to the testicular artery, lymphatic vessels, and vas deferens, to improve the identification of all veins to reduce the chance of reoccurrence of the varicoseal, and to reduce the risk of a hydrosil, which is a collection of watery fluid around the testicle after surgery. Some surgeons choose to perform a laparoscopic repair. Laparoscopic surgery involves performing an operation using special instruments passed into the body through tiny incisions in the skin. The procedure is visualized on a video monitor connected to a video telescope also passed in the body this way. It was initially thought that this type of surgery would allow for quicker recovery time following varicoseal repair, as it does for other operations. However, it proved unfortunately to be associated with a higher risk of more severe, rare complications. It can also take longer than the traditional open surgery. For these reasons, laparoscopic varicoseal repair is no longer offered in many centers. Regardless of the type of surgery performed, once the operation is completed, the incision in the skin is close together with tiny dissolvable stitches and you are transferred to a recovery area or day surgery unit. After a short period of observation, you will be discharged home with a family member or friend. It is recommended to stay off work for one week and to perform only light activities for two weeks after the operation. Following surgery, your doctor will outline your post-operative care. It is often recommended that you keep the wound dry for 24 hours and avoid bathing for at least 48 hours. If you experience discomfort after the procedure, it is best to take an over-the-counter painkiller such as acetaminophen or ibuprofen. Your doctor may prescribe something stronger than this to use if necessary. It is normal following varicoseal surgery to have some mild discomfort in the scrotum or groin and some mild bruising or swelling of the skin. A slight bit of blood from the wound is also within normal. In general, the risk of complications following varicoseal repair is quite low. Having said this, it is a surgical procedure and complications can develop. Things to consider or watch for include an infection or abscess under the skin, which might occur in less than 1% of cases, a collection of blood or fluid in the scrotum, called a hydroseal, which might occur in up to 3% of cases, and reoccurrence or persistence of the varicoseal after surgery, which has been reported to occur in about 7% of cases. With this in mind, you should call your doctor or other healthcare provider if you develop any of the following. A high fever that persists, drainage of pus through the incision, or a large collection of fluid around the testicle. Unfortunately, having a varicoseal repair does not guarantee successful pregnancy or complete reduction in pain. For patients experiencing problems with fertility, where the varicoseal is felt to be a factor, improvements on semen analysis are likely to be seen in 60% of cases following surgery. This may translate to a pregnancy rate in the order of 40%, although this is difficult to accurately determine from research studies. In adolescents, testicular growth will usually be observed, or the size of the affected testicle catches up to normal. When done for pain, unfortunately, results are highly variable, and one simply cannot guarantee successful resolution of pain. This is because the cause of pain is so difficult to diagnose and pinpoint, and the pain response is so complex that even when a varicoseal is found in relation to pain in that area, it is not necessarily the lone cause of that pain. Percutaneous means through the skin, and usually refers to procedures performed by passing a needle into the body and performing a procedure using this point of access. A percutaneous occlusion of a varicoseal involves passing a needle into a large vein in the leg, guiding it by x-ray up and around to the testicular vein, as shown in this diagram, then using special materials such as coils, balloons, or other products to occlude or block off the testicular vein and varicoseal. This procedure is performed by a specialized doctor called an interventional radiologist, and is usually performed in the diagnostic imaging, or x-ray department, of a hospital or clinic. It usually requires only local anesthesia or freezing. Percutaneous occlusion has the disadvantage of possibly taking longer than most other techniques, but the advantage of avoiding the need for general anesthetic. It also allows for quicker recovery. Success rates with this procedure depend largely on the technical experience and expertise of the center and the clinical situation. For example, the procedure can be more difficult in adolescents with small veins and in men with varicoseals on both sides. Overall, slightly higher recurrence rates have been reported compared to surgery in the order of 10%. Again, however, this will vary from center to center. Technical problems limiting the ability to carry out the procedure have been reported in about 10% of cases. Percutaneous occlusion is generally a safe procedure, however minor complications can rarely occur, such as bleeding at the skin puncture site, mild infection or inflammation, or fainting. A more serious but rare complication can occur if the occluding material migrates out of position and is carried elsewhere by the bloodstream. If you think you do have a varicoseal, firstly, do not worry, as this is a common and for most men, harmless condition. If you are concerned about a fertility problem, see your doctor who can confirm the diagnosis. Remember that 87% of men with a varicoseal have good fertility and are able to father children. If one of your testicles is significantly smaller than the other or if you have ongoing testicular pain, see your doctor for an evaluation. Also, if you think you have a varicoseal on the right side only, you should seek medical attention. In summary, varicoseals are dilated veins that drain blood from the testicles. They are very common and usually harmless, but may require treatment if they are thought to be affecting fertility, testicular growth, or causing pain. Treatment of varicoseals may involve surgery or percutaneous occlusion. These are relatively minor outpatient procedures. Overall, they are safe, and they can be very effective, especially in improving testicular growth for adolescents and for improving fertility in certain men. These resources on the Internet may help you find further information or support about your condition. Current references were used to assist in the preparation of this module. All of these are available through your local medical library if you are interested in more detailed reading on this subject. We sincerely hope that this module has furthered your understanding of varicoseals. We wish you the best for the future, and thank you once again for viewing this educational program.