Guidelines for the Prevention and Treatment of Varicocele, and Essential Information for Men's Health

Varicocele (spermia) is defined as the dilation, tortuosity, and elongation of the pampiniform plexus of veins in the spermatic cord. It is most common in young men, typically occurring between the ages of 16 and 25, with an incidence rate of approximately 15%. 99% of cases occur on the left side, with bilateral cases accounting for about 1%.

Patients may be completely asymptomatic, with the condition only discovered during a physical examination. Symptoms include a feeling of heaviness or pain in the scrotum or testicle on the affected side, scrotal swelling, and the affected side's scrotum and testicle being lower than the healthy side when standing. Dilated and tortuous veins are visible on the surface of the scrotum. A soft, worm-like mass can be palpated, and symptoms may lessen or disappear when lying down. Patients may experience neurasthenia symptoms such as headache, fatigue, and nervousness. Some patients may experience sexual dysfunction. Varicocele can sometimes affect fertility. 9% of men with varicocele are infertile, and 39% of male infertility is caused by varicocele. In severe cases, varicocele can lead to testicular atrophy. This is because the temperature inside the scrotum on the affected side rises and reflects to the opposite side, causing spermatogonia to degenerate and atrophy, resulting in a reduced sperm count. Alternatively, serotonin or steroids secreted by the left adrenal gland may reflux into the testis via the left spermatic vein, causing a decrease in sperm count.

Clinically, varicocele can be classified into three degrees: Mild: When standing, varicose veins are not visible on the scrotal skin, but can be felt within the scrotum; the varicose veins disappear quickly when lying down. Moderate: When standing, dilated veins are visible on the scrotum, and more obvious varicose veins can be felt within the scrotum; the mass gradually disappears when lying down. Severe: Obvious, large blood vessels are visible on the surface of the scrotum, and obvious worm-like varicose veins are present within the scrotum; the vein walls are thickened and hardened; the varicose veins disappear slowly when lying down.

【Treatment Methods】 Mild, asymptomatic varicocele does not require treatment. Mild varicocele, or varicocele accompanied by neurasthenia, can be treated with a scrotal support and cold compresses.

For more severe varicocele, sperm counts below 20 million for three consecutive tests, testicular atrophy, or cases where the varicose veins disappear when lying down, high ligation of the internal spermatic vein may be performed.

Surgical approaches include the inguinal canal approach via the internal spermatic vein. This method is similar to the hernia incision, exposing the spermatic cord, locating the main trunk and branches of the internal spermatic vein, and ligating them. This approach is simple and therefore commonly used. Dilated external spermatic veins and testicular girdle veins can be ligated simultaneously. Using a surgical microscope during the procedure improves the results, reduces recurrence, and minimizes complications. Another approach is the iliac fossa approach, involving a left lower quadrant oblique incision, pushing back the peritoneum, and ligating the internal spermatic vein retroperitoneally and anterior to the external iliac artery. The advantage is that accidental injury to the internal spermatic artery at this location will not cause testicular atrophy. The disadvantage is that it cannot simultaneously treat communicating branches. Recently, some researchers have inserted a catheter through the inferior vena cava and left renal vein to the left internal spermatic vein, then injected 5% sodium morrhuate or gelatin sponge with a steel coil to embolize this vein to treat varicocele.

The disadvantages of this procedure are that it is unsuitable for embolization in cases of venous malformation or collateral circulation, and it requires specialized equipment.