A varicocele is a common medical condition characterized by the abnormal enlargement of veins within the scrotum, resembling varicose veins found in the legs. This condition affects the pampiniform plexus, a network of veins that drains blood from the testicles. While often associated with the left side, a bilateral varicocele specifically involves the enlargement of these veins in both testicles.
What is Bilateral Varicocele?
Bilateral varicocele refers to the dilation and tortuosity of the pampiniform plexus veins affecting both testicles. This condition arises when the one-way valves inside the spermatic veins, responsible for directing blood flow back to the heart, become incompetent or fail. Blood then pools and flows backward, leading to enlarged and twisted veins.
Varicocele affects 15-20% of the male population. Among men diagnosed, up to 50% may have bilateral involvement, though the left side is more commonly affected. This bilateral occurrence can sometimes be subclinical on one side, meaning it is not immediately obvious without specific diagnostic imaging.
Recognizing the Symptoms
Individuals with bilateral varicocele may experience a range of symptoms, though some have no noticeable signs. A common complaint is a dull ache or discomfort in the scrotum, which can worsen throughout the day or with physical exertion, such as prolonged standing or heavy lifting. This discomfort is often relieved by lying down.
A feeling of heaviness in the scrotum is another symptom, attributed to the pooling of blood in the enlarged veins. Visible or palpable enlarged veins, often described as feeling like a “bag of worms,” can be detected above one or both testicles.
Bilateral varicocele can also lead to testicular atrophy, where one or both testicles may appear noticeably smaller than their normal size due to impaired blood supply.
Diagnosing Bilateral Varicocele
The diagnostic process for bilateral varicocele begins with a physical examination. A healthcare provider will palpate, or feel, the scrotum while the patient is standing, often asking them to perform the Valsalva maneuver. This maneuver, which involves taking a deep breath and bearing down, increases abdominal pressure and can make enlarged veins more prominent and easier to detect.
Scrotal ultrasound with color-flow Doppler is the primary imaging tool to confirm diagnosis. It visually confirms dilated veins in the pampiniform plexus, with a vessel diameter of 2-3 mm or greater indicating abnormal distension. The ultrasound also assesses blood flow, looking for reflux (backward flow), especially during the Valsalva maneuver. A prolonged reflux over one second is a diagnostic indicator. If a secondary cause for the varicocele, such as a retroperitoneal tumor, is suspected, additional imaging tests might be performed.
Treatment Options
Treatment for bilateral varicocele depends on the severity of symptoms, the presence of testicular atrophy, and concerns about fertility. For individuals with mild symptoms or no significant impact on testicular function, conservative management may be recommended. This approach can involve supportive underwear, such as briefs or a jockstrap, to alleviate discomfort and over-the-counter pain relievers for occasional aches.
When symptoms are bothersome, or if there is evidence of testicular atrophy or impaired fertility, interventional options are considered. Surgical ligation, known as varicocelectomy, involves tying off the affected veins to redirect blood flow through healthy ones. This can be performed through open surgery, which involves a small incision in the groin or lower abdomen, or a minimally invasive laparoscopic approach using small incisions and specialized instruments.
Microsurgery, a type of open surgery, utilizes a microscope to precisely identify and ligate the problematic veins, which can lead to fewer complications and a lower recurrence rate. Another interventional option is percutaneous embolization, a minimally invasive procedure performed by an interventional radiologist. A small catheter is inserted into a vein, often in the groin or neck, and guided to the affected spermatic veins using X-ray imaging. Small metal coils or a sclerosant (a special medication) are then released into the vein to block blood flow, causing the varicocele to shrink. This procedure requires local anesthesia and offers a quicker recovery time compared to surgical approaches. For bilateral varicoceles, embolization can treat both sides through a single access point.
Impact on Fertility and Long-Term Considerations
Bilateral varicocele can affect male fertility by creating an environment in the scrotum that is less conducive to healthy sperm production. The impaired blood flow and subsequent pooling of blood in the enlarged veins can lead to an increase in scrotal temperature. This elevated temperature can negatively impact spermatogenesis, the process of sperm development, and also contribute to oxidative stress, which can damage sperm DNA and reduce sperm quality, including count and motility.
Treatment of bilateral varicocele may lead to improvements in sperm parameters for some individuals, potentially increasing the chances of natural conception. However, the degree of improvement can vary, and not all men will experience a significant change in fertility outcomes. Long-term considerations for bilateral varicocele include the possibility of testicular atrophy progressing if the condition remains untreated. While treatment can halt or reverse testicular shrinkage, the extent of recovery depends on the duration and severity of the atrophy. There is also a possibility of varicocele recurrence after treatment, although success rates for both surgical and embolization procedures are high.