Varicocele

To understand how a varicose vein or varicocele emerges it is neces­sary to know something about the blood supply to the testicles, or rather the drainage of blood. Venal blood leaves the testicles via the left and right testicular veins (vena spermatica interna). The right-hand vessel discharges into the inferior vena cava, which transports low — oxygen blood back to the heart. In the case of the left-hand testicular vein the situation is slightly different: it discharges into the left-hand renal vein, which transports blood purified in the left kidney to the vena cava. Since no organ, including a testicle, likes used blood, which con­tains waste matter, there are, especially in the left testicular vein, valves
that prevent the blood from flowing back to the testicle. If those valves do not function properly it is possible that blood from the left renal artery will flow back, resulting in the formation of a varicose vein just above the left testicle, where there is a dense network of blood vessels (the plexus pampiniformis). This can lead to nagging pain, especially in men who stand up all day long. The accumulation of venal blood may cause the local temperature to rise, with possible harmful effects on fertility. But if the left testicle no longer functions properly, surely that won’t affect the right one? You’d certainly think not, but in practice in a number of cases of varicose veins venal blood flows back on the right — hand side too. This is because there are communication channels between the left and right side, but gravity undoubtedly also plays a part, since varicose veins have never yet been observed in the scrotums of quad­rupeds. Apart from that, varicose veins differ widely. Quite a few men, estimated at between io and 18 per hundred, have a varicose vein, but by no means everyone has a problem with it. Some 30 per cent of all men who consult a doctor because of involuntary childlessness have such a vein.

Making the diagnosis is generally quite simple. In half of patients the varicose vein is either visible to the naked eye or can be felt with the hand. In order to be able to assess the whole situation, the doctor will ask the patient to blow on the back of his hand briefly. A manoeuvre like this propels venal blood and causes the vein in the scrotum to swell considerably. If the doctor is not sure of his or her ground, he or she will ask for an ecograph of the scrotum. Surgery is by no means always called for in all cases of varicocele. With most men it is sufficient to advise the use of a tight-fitting pair of underpants. Only if the patient wishes to have children is treatment worthwhile. Researchers from Rotterdam showed recently in an excellent study that treating a varico-

cele significantly improves the chances of spontaneous pregnancy in the partner. There are three various possible treatments: surgically via an incision to the left of the navel, the groin or the scrotum, but also with an embolization in which a catheter is passed through the inguinal vein to the renal vein, after which a plug closure is inserted in the vena spermatica interna. The third possibility is a keyhole operation in which the vein is clipped. There is scarcely any difference between the success rates of the various treatments.