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Varicoceles: Overview of Treatment from a Radiologic and Surgical Perspective (2022)
Helio V. Neves da Silva, BS Robert L. Meller, MD Eniola A. Ogundipe, MD Paul J. Rochon, MD, FSIR
A testicular varicocele is the result of the expansion of the venous pampiniform plexus of the scrotum. Often painless, a significant number of patients experience orchialgia, swelling, testicular atrophy, and abnormalities in spermatic parameters. Treatment of symptomatic varicocele involves a radiologic or surgical intervention to obstruct the reflux of venous drainage. Testicular anatomy, diagnostic evaluation and imaging, options for surgical intervention, and a step-by-step description of retrograde embolization and antegrade scrotal sclerotherapy are discussed. Furthermore, included is an overview of postprocedural management and patient outcomes for radiological interventions, and the most up-to-date evidence on the efficacy of varicocele treatments as well as how they compare to each other.
A varicocele is an abnormal dilation and subsequent expansion of the venous pampiniform plexus of the scrotum, which drains blood from the testicles.1 It is typically characterized as a “bag of worms” on physical examination. Often painless, severe cases present with a history of dull, aching pain that is worse with increased activity, standing, and straining.2 Symptomatic patients may also present with scrotal swelling or testicular atrophy.
Varicoceles are classified as primary or secondary. Primary varicoceles make up the majority of cases and are defined by incompetent gonadal venous valves with resulting reflux; secondary varicoceles are much less common and are the result of increased pressure in the vein from either compression or obstruction.3 Causes include compression from extrinsic masses or lymphadenopathy as well as obstruction from renal vein thrombosis. The left testis is more commonly involved making up approximately 90% of cases, while approximately 9% of cases are bilateral. Unilateral right-sided varicoceles are very rare comprising approximately 1% of cases. If an isolated right-sided varicocele is encountered, an additional workup for secondary causes should be performed.1
In addition to being a cause of orchialgia, varicoceles are the most common cause of abnormal sperm morphology, abnormal semen analysis, decreased sperm motility, and low sperm count.1,4 The significant morbidity caused by varicocele affects 15 to 20% of adult men and nearly 40% of infertile men.1,2 This prevalence increases with age, as varicoceles affect over 40% of the elderly population.5 The exact cause of infertility in patients with varicocele is unclear; however, the most important factor is likely increased scrotal temperature. Additional factors may include reflux of toxic metabolites as well as hypoxia related to venous stasis.6–8
The treatment of varicocele involves surgical or procedural interventions, as pharmacological therapies do not provide a definitive solution to this anatomical problem.9 Surgical intervention to treat varicocele varies in approach and shares the goal of obstructing the reflux of venous drainage while avoiding the vas deferens and the testicular artery.10–13 Meanwhile, radiological treatment can occur via embolization or sclerotherapy.14
Treatment for varicoceles should be reserved for symptomatic patients with pain, mass effect, bothersome appearance, or infertility, as treatment has been shown to efficiently improve the pain and decrease the size of large varicoceles.14–16 Analgesics and scrotal support are alternatives to relieve pain or discomfort experienced by patients.1 When intervention is warranted, varicocele can be treated via surgery or radiological intervention. Due to a lack of consensus on how varicoceles should be graded, it should be at the physician’s discretion to decide when to intervene based on history, physical exam, and imaging findings.17
In this article, an outline of the current evidence and practice of radiological interventions for varicocele and a brief overview of the diagnosis and management of this disease will be discussed. With images and step-by-step explanations, the authors focus on describing both retrograde embolization and antegrade sclerotherapy, comparing these treatments with other available interventions based on recent evidence.
*Anatomy
*Evaluation and Diagnostic Imaging
*Surgical Interventions
-Retrograde Embolization
-Antegrade Scrotal Sclerotherapy
*Postprocedural Follow-up for Radiological Interventions
-Outcomes
*Radiological versus Surgical Interventions
Conclusion
Procedural intervention for symptomatic testicular varicocele has been shown to improve pain and spermatic parameters and increases the chance of pregnancy. Current evidence suggests that radiologic treatment offers a lower risk of complications and a quicker postoperative recovery compared to surgical intervention. Overall success rates, spermatic parameters, and pregnancy rates between radiologic and surgical techniques are comparable. Radiologic and surgical techniques are both efficacious and safe; thus treatment courses should be determined by the physician to best fit their patient’s needs.
Helio V. Neves da Silva, BS Robert L. Meller, MD Eniola A. Ogundipe, MD Paul J. Rochon, MD, FSIR
A testicular varicocele is the result of the expansion of the venous pampiniform plexus of the scrotum. Often painless, a significant number of patients experience orchialgia, swelling, testicular atrophy, and abnormalities in spermatic parameters. Treatment of symptomatic varicocele involves a radiologic or surgical intervention to obstruct the reflux of venous drainage. Testicular anatomy, diagnostic evaluation and imaging, options for surgical intervention, and a step-by-step description of retrograde embolization and antegrade scrotal sclerotherapy are discussed. Furthermore, included is an overview of postprocedural management and patient outcomes for radiological interventions, and the most up-to-date evidence on the efficacy of varicocele treatments as well as how they compare to each other.
A varicocele is an abnormal dilation and subsequent expansion of the venous pampiniform plexus of the scrotum, which drains blood from the testicles.1 It is typically characterized as a “bag of worms” on physical examination. Often painless, severe cases present with a history of dull, aching pain that is worse with increased activity, standing, and straining.2 Symptomatic patients may also present with scrotal swelling or testicular atrophy.
Varicoceles are classified as primary or secondary. Primary varicoceles make up the majority of cases and are defined by incompetent gonadal venous valves with resulting reflux; secondary varicoceles are much less common and are the result of increased pressure in the vein from either compression or obstruction.3 Causes include compression from extrinsic masses or lymphadenopathy as well as obstruction from renal vein thrombosis. The left testis is more commonly involved making up approximately 90% of cases, while approximately 9% of cases are bilateral. Unilateral right-sided varicoceles are very rare comprising approximately 1% of cases. If an isolated right-sided varicocele is encountered, an additional workup for secondary causes should be performed.1
In addition to being a cause of orchialgia, varicoceles are the most common cause of abnormal sperm morphology, abnormal semen analysis, decreased sperm motility, and low sperm count.1,4 The significant morbidity caused by varicocele affects 15 to 20% of adult men and nearly 40% of infertile men.1,2 This prevalence increases with age, as varicoceles affect over 40% of the elderly population.5 The exact cause of infertility in patients with varicocele is unclear; however, the most important factor is likely increased scrotal temperature. Additional factors may include reflux of toxic metabolites as well as hypoxia related to venous stasis.6–8
The treatment of varicocele involves surgical or procedural interventions, as pharmacological therapies do not provide a definitive solution to this anatomical problem.9 Surgical intervention to treat varicocele varies in approach and shares the goal of obstructing the reflux of venous drainage while avoiding the vas deferens and the testicular artery.10–13 Meanwhile, radiological treatment can occur via embolization or sclerotherapy.14
Treatment for varicoceles should be reserved for symptomatic patients with pain, mass effect, bothersome appearance, or infertility, as treatment has been shown to efficiently improve the pain and decrease the size of large varicoceles.14–16 Analgesics and scrotal support are alternatives to relieve pain or discomfort experienced by patients.1 When intervention is warranted, varicocele can be treated via surgery or radiological intervention. Due to a lack of consensus on how varicoceles should be graded, it should be at the physician’s discretion to decide when to intervene based on history, physical exam, and imaging findings.17
In this article, an outline of the current evidence and practice of radiological interventions for varicocele and a brief overview of the diagnosis and management of this disease will be discussed. With images and step-by-step explanations, the authors focus on describing both retrograde embolization and antegrade sclerotherapy, comparing these treatments with other available interventions based on recent evidence.
*Anatomy
*Evaluation and Diagnostic Imaging
*Surgical Interventions
-Retrograde Embolization
-Antegrade Scrotal Sclerotherapy
*Postprocedural Follow-up for Radiological Interventions
-Outcomes
*Radiological versus Surgical Interventions
Conclusion
Procedural intervention for symptomatic testicular varicocele has been shown to improve pain and spermatic parameters and increases the chance of pregnancy. Current evidence suggests that radiologic treatment offers a lower risk of complications and a quicker postoperative recovery compared to surgical intervention. Overall success rates, spermatic parameters, and pregnancy rates between radiologic and surgical techniques are comparable. Radiologic and surgical techniques are both efficacious and safe; thus treatment courses should be determined by the physician to best fit their patient’s needs.
