Do varicoceles (varicose veins in the scrotum) affect seminal vesicles?

Impact of Varicoceles on Seminal Vesicles

Varicoceles do not directly affect seminal vesicles, but rather primarily impact testicular function through increased scrotal temperature, testicular hypoxia, and reflux of toxic metabolites causing DNA damage. 1

Varicocele Pathophysiology and Reproductive Impact

• Varicoceles are present in approximately 15% of the general male population but occur in 35-40% of men presenting with infertility, demonstrating a significant association with fertility problems 1
• The primary mechanisms of fertility impairment from varicoceles include:
  • Increased scrotal temperature
  • Testicular hypoxia
  • Reflux of toxic metabolites that cause testicular dysfunction 1
• These mechanisms lead to impaired spermatogenesis rather than direct effects on seminal vesicles 2

Diagnostic Considerations

• Physical examination remains the primary method for diagnosing clinically significant varicoceles 3
• Routine use of ultrasonography to identify non-palpable (subclinical) varicoceles is discouraged as treatment of these varicoceles is not associated with improved fertility outcomes 1
• When evaluating men with suspected ejaculatory duct obstruction (acidic, azoospermic semen with volume <1.5mL), transrectal ultrasound (TRUS) is recommended to evaluate for anatomic abnormalities, which may include seminal vesicle assessment 3
• Clinicians should not routinely perform abdominal imaging for isolated small or moderate right varicoceles 3

Treatment Implications

• Varicocele repair should be targeted specifically to men with:
  • Clinical (palpable) varicoceles
  • Abnormal semen parameters 4, 1
• Treatment of subclinical varicoceles or men with normal semen analysis is not recommended regardless of hormonal status 4
• After varicocele repair, improvements in semen parameters typically take 3-6 months (two spermatogenic cycles) to manifest 4, 5
• The European Association of Urology strongly recommends surgery for varicocele when associated with a persistent small testis (size difference >2 mL or 20%), confirmed on two subsequent visits 6 months apart 6

Hormonal Considerations

• Varicoceles can cause hormonal alterations including:
  • Decreased testosterone levels
  • Higher FSH and LH levels
  • Lower circulating Anti-Müllerian Hormone and Inhibin-B levels (indicating decreased Sertoli cell function) 7
• These hormonal changes typically improve after varicocelectomy, paralleling improvements in semen parameters 4

Treatment Options and Outcomes

• Main procedures for varicocele repair include:
  • Microsurgical subinguinal or inguinal varicocelectomy
  • Laparoscopic varicocelectomy
  • Radiological percutaneous embolization 5
• Sclerotherapy has shown promising results with:
  • Significant increases in sperm concentration, progressive and total motility
  • Lower varicocele recurrence rates (19.7%) compared to surgical varicocelectomy (32%)
  • Higher pregnancy rates (28%) compared to surgical varicocelectomy (13%) 8
• Spontaneous pregnancy typically occurs between 6-12 months after varicocelectomy 1

Clinical Pitfalls and Considerations

• Varicoceles can occur concomitantly with other conditions causing impaired spermatogenesis, which may complicate diagnosis and treatment 5
• Severe varicoceles show greater improvement in sperm count after surgical repair compared to moderate or mild varicoceles 1
• Earlier intervention may prevent permanent testicular damage 6
• If infertility persists after 6 months post-treatment, other therapies including assisted reproductive technology should be considered, especially in older couples 5