Advertisement

Varicocele and Orchialgia

  • Benjamin J. McCormick
  • R. Matthew Coward
Chapter

Abstract

A varicocele is the abnormal dilation and tortuosity of the pampiniform plexus of veins in the spermatic cord. Varicoceles affect approximately 15% of the male population. While the majority of men with varicoceles are asymptomatic, about 10% of patients may experience pain. The pain associated with varicoceles is typically restricted to the ipsilateral scrotum, is described as dull and achy, and is typically exacerbated by prolonged periods of standing or activity. A varicocele implicated as the etiology of chronic orchialgia is a diagnosis of exclusion, and a thorough history and physical examination must be performed to rule out other causes of pain, paying particular attention to atypical signs or symptoms. Adjunctive studies such as urinalysis and urine culture should be obtained if indicated. Though imaging is not necessary or indicated for the diagnosis of varicocele, several imaging modalities including ultrasound, CT, and MRI are often useful in the evaluation of other potential causes of chronic orchialgia. Additionally, given the known effect of varicoceles on fertility, a thorough sexual and reproductive history should be obtained, and a fertility evaluation should be offered. Initial management for suspected varicocele-related orchialgia should be aimed at conservative measures, including nonsteroidal anti-inflammatory (NSAIDs) drugs or medications, scrotal support, activity limitations, and a 6-month-long period of observation to allow other sources of pain to present themselves or resolve. If conservative measures fail to adequately manage the pain, or if activity limitations are not feasible, procedural intervention may be indicated. While the microsurgical subinguinal approach is the gold standard, surgical repair has been shown to be effective in treating varicocele-related chronic orchialgia, regardless of approach, with approximately 90% of patients experiencing significant improvement or complete resolution of pain with infrequent and mild complications.

Keywords

Varicocele orchialgia testicular pain scrotal pain varicocele repair varicocelectomy 

References

  1. 1.
    Lomboy JR, Coward RM. The varicocele: clinical presentation, evaluation, and surgical management. Semin Intervent Radiol. 2016;33(3):163–9.CrossRefGoogle Scholar
  2. 2.
    Thomason AM, Fariss BL. The prevalence of varicoceles in a group of healthy young men. Mil Med. 1979;144(3):181–2.CrossRefGoogle Scholar
  3. 3.
    Damsgaard J. Varicocele is associated with impaired semen quality and reproductive hormone levels: a study of 7035 healthy young men from six European countries. Eur Urol. 2016;70:1019–29.CrossRefGoogle Scholar
  4. 4.
    Gorelick JI, Goldstein M. Loss of fertility in men with varicocele. Fertil Steril. 1993;59(3):613–6.CrossRefGoogle Scholar
  5. 5.
    Witt M. Outcomes of varicocele ligation done for pain. J Urol. 1998;42:541–3.CrossRefGoogle Scholar
  6. 6.
    Peterson AC, Lance RS, Ruiz HE. Outcomes of varicocele ligation done for pain. J Urol. 1998;159(5):1565–7.CrossRefGoogle Scholar
  7. 7.
    Parekattil SJ, Gudeloglu A, Brahmbhatt JV, Priola KB, Vieweg J, Allan RW. Trifecta nerve complex: potential anatomical basis for microsurgical denervation of the spermatic cord for chronic orchialgia. J Urol. 2013;190(1):265–70.CrossRefGoogle Scholar
  8. 8.
    Khera M, Lipshultz LI. Evolving approach to the varicocele. Urol Clin North Am. 2008;35(2):183–9, viii.CrossRefGoogle Scholar
  9. 9.
    Practice Committee of the American Society for Reproductive Medicine, Society for Male Reproduction and Urology. Report on varicocele and infertility: a committee opinion. Fertil Steril. 2014;102(6):1556–60.CrossRefGoogle Scholar
  10. 10.
    Amelar RD, Dubin L. Therapeutic implications of left, right, and bilateral varicocelectomy. Urology. 1987;30(1):53–9.CrossRefGoogle Scholar
  11. 11.
    Dubin L, Amelar RD. Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Fertil Steril. 1970;21(8):606–9.CrossRefGoogle Scholar
  12. 12.
    Benson JS, Abern MR, Larsen S, Levine LA. Does a positive response to spermatic cord block predict response to microdenervation of the spermatic cord for chronic scrotal content pain? J Sex Med. 2013;10(3):876–82.CrossRefGoogle Scholar
  13. 13.
    Levine LA, Matkov TG. Microsurgical denervation of the spermatic cord as primary surgical treatment of chronic orchialgia. J Urol. 2001;165(6):1927–9.CrossRefGoogle Scholar
  14. 14.
    Yaman Ö, Özdi̇ler E, Anafarta K, Göğüş O. Effect of microsurgical subinguinal varicocele ligation to treat pain. Urology. 2000;55(1):107–8.CrossRefGoogle Scholar
  15. 15.
    Chen S-S. Factors predicting symptomatic relief by varicocelectomy in patients with normospermia and painful varicocele nonresponsive to conservative treatment. Urology. 2012;80(3):585–9.CrossRefGoogle Scholar
  16. 16.
    Male Infertility Best Practice Policy Committee of the American Urological A, Practice Committee of the American Society for Reproductive M. Report on varicocele and infertility. Fertil Steril. 2004;82(Suppl 1):S142–5.Google Scholar
  17. 17.
    Park HJ, Lee SS, Park NC. Predictors of pain resolution after varicocelectomy for painful varicocele. Asian J Androl. 2011;13(5):754–8.CrossRefGoogle Scholar
  18. 18.
    Abd Ellatif ME, Asker W, Abbas A, Negm A, Al-Katary M, El-Kaffas H, et al. Varicocelectomy to treat pain, and predictors of success: a prospective study. Curr Urol. 2012;6(1):33–6.CrossRefGoogle Scholar
  19. 19.
    Altunoluk B, Soylemez H, Efe E, Malkoc O. Duration of preoperative scrotal pain may predict the success of microsurgical varicocelectomy. Int Braz J Urol. 2010;36(1):55–9.CrossRefGoogle Scholar
  20. 20.
    Zhang H, Liu X-P, Yang X-J, Huang W-T, Ruan X-X, Xiao H-J, et al. Loupe-assisted versus microscopic varicocelectomy: is there an intraoperative anatomic difference? Asian J Androl. 2014;16(1):112.CrossRefGoogle Scholar
  21. 21.
    Guo L, Sun W, Shao G, Song H, Ge N, Zhao S, et al. Outcomes of microscopic subinguinal varicocelectomy with and without the assistance of Doppler ultrasound: a randomized clinical trial. Urology. 2015;86(5):922–8.CrossRefGoogle Scholar
  22. 22.
    Marmar J, Kim Y. Subinguinal microsurgical varicocelectomy: a technical critique and statistical analysis of semen and pregnancy data. J Urol. 1994;152(4):1127–32.CrossRefGoogle Scholar
  23. 23.
    Kim SO, Jung H, Park K. Outcomes of microsurgical subinguinal varicocelectomy for painful varicoceles. J Androl. 2012;33(5):872–5.CrossRefGoogle Scholar
  24. 24.
    Kenan K, Temuçin Ş, Kadir B, Ferhat A, Cüneyd I, Doğan E. Evaluation of the role of varicocelectomy including external spermatic vein ligation in patients with scrotal pain. Int J Urol. 2005;12(5):484–8.CrossRefGoogle Scholar
  25. 25.
    Kachrilas S, Popov E, Bourdoumis A, Akhter W, El Howairis M, Aghaways I, et al. Laparoscopic varicocelectomy in the management of chronic scrotal pain. JSLS. 2014;18(3):e2014.00302.CrossRefGoogle Scholar
  26. 26.
    Maghraby HA. Laparoscopic varicocelectomy for painful varicoceles: merits and outcomes. J Endourol. 2002;16(2):107–10.CrossRefGoogle Scholar
  27. 27.
    Chawla A, Kulkarni G, Kamal K, Zini A. Microsurgical varicocelectomy for recurrent or persistent varicoceles associated with orchalgia. Urology. 2005;66(5):1072–4.CrossRefGoogle Scholar
  28. 28.
    Cassidy D, Jarvi K, Grober E, Lo K. Varicocele surgery or embolization: which is better? Can Urol Assoc J. 2012;6(4):266.CrossRefGoogle Scholar
  29. 29.
    Abdulmaaboud MR, Shokeir AA, Farage Y, El-Rahman AA, El-Rakhawy MM, Mutabagani H. Treatment of varicocele: a comparative study of conventional open surgery, percutaneous retrograde sclerotherapy, and laparoscopy. Urology. 1998;52(2):294–300.CrossRefGoogle Scholar
  30. 30.
    Puche-Sanz I, Floes-Martín J, Vázquez-Alonso F, Pardo-Moreno P, Cózar-Olmo J. Primary treatment of painful varicocoele through percutaneous retrograde embolization with fibred coils. Andrology. 2014;2(5):716–20.CrossRefGoogle Scholar
  31. 31.
    Halpern J, Mittal S, Pereira K, Bhatia S, Ramasamy R. Percutaneous embolization of varicocele: technique, indications, relative contraindications, and complications. Asian J Androl. 2016;18(2):234.CrossRefGoogle Scholar
  32. 32.
    Tung M-C, Huang WJ, Chen K-K. Modified subinguinal varicocelectomy for painful varicocele and varicocele-associated infertility. J Chin Med Assoc. 2004;67(6):296–300.PubMedGoogle Scholar
  33. 33.
    Parekattil SJ, Brahmbhatt JV. Robotic approaches for male infertility and chronic orchialgia microsurgery. Curr Opin Urol. 2011;21(6):493–9.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Benjamin J. McCormick
    • 1
  • R. Matthew Coward
    • 1
  1. 1.Department of UrologyUniversity of North Carolina School of MedicineChapel HillUSA

Personalised recommendations