Varicocele embolization

A varicocele is a group of swollen veins in the scrotum, like a varicose vein in the leg. Blood normally drains from the testicle up through a long vein in the belly called the gonadal vein (or testicular vein). This vein has one-way valves. When the valves do not close well, blood pools and flows backward, and the small veins around the testicle stretch.

Varicoceles affect about 15 in 100 men and are much more common on the left side, because of the way the left vein drains. They often appear in the teen years. Many cause no problems at all. Some cause a dull ache or heaviness, a smaller testicle, or lower sperm quality. For more on the condition itself, see varicocele.

Varicocele embolization treats the cause: it closes the leaking gonadal vein from the inside so blood reroutes through healthy veins. Embolization means blocking a blood vessel on purpose.

A varicocele that appears suddenly in an adult, especially on the right side or one that does not go down when you lie flat, can rarely be a sign of something pressing on the vein in the belly. We check for this with imaging before treating.

The main alternative is surgical varicocelectomy, where a urologist ties off the veins through a small cut in the groin or lower belly, often using a microscope (microsurgical varicocelectomy). Both approaches work well. The best choice depends on your anatomy, your goals and your preference.

Embolization also treats veins that are hard to see at surgery and is a good option when a varicocele comes back after an operation. In a small number of men, usually fewer than 1 in 10, the vein cannot be safely closed during embolization, and surgery is then the next step. Medicines do not fix a varicocele, though anti-inflammatories and supportive underwear can ease mild aching.

1. 1
   Getting comfortable

   An IV is placed and you receive moderate sedation, so you are relaxed and drowsy but breathing on your own. The skin over a vein in the neck, arm or groin is numbed.

2. 2
   Reaching the vein

   Using ultrasound, we place a small tube in the vein. A thin catheter is guided down to the kidney vein and into the gonadal vein, watching on X-ray.

3. 3
   Closing the leaking vein

   Contrast dye shows the backward flow. We close the vein and its side branches with tiny soft metal coils, a foam sclerosant (a medicine that seals the vein lining), or both.

4. 4
   Finishing

   A final picture confirms the backward flow has stopped. The tube is removed and a small bandage is placed. No stitches are needed.

The whole procedure takes about an hour, sometimes longer when both sides are treated. You may feel a brief warm sensation when dye is injected, and some men feel a mild ache in the lower belly or back when the vein is closed.

On the venogram, the healthy gonadal vein does not fill when dye is injected into the kidney vein. With a varicocele, dye runs backward down a wide vein into a tangle of veins in the scrotum. After embolization, the coils appear as small white springs and the dye stops above them.

What I look for on the venogram is every path the blood can take back down to the scrotum, not just the main vein. Missing a small side channel is the most common reason a varicocele comes back, so I take the time to find and close them. I tell men to expect a bit of aching for a few days and to be patient with fertility results, because new sperm take about three months to develop.

Fabio Komlos, MD, interventional radiologist · About Dr. Fabio Komlos

1. First 1–2 hours
   You rest in recovery while nurses check the puncture site. Then you go home with an adult driver.
2. First day
   Rest. No driving, alcohol or important decisions for 24 hours after sedation. You may shower the next day.
3. Days 1–3
   A dull ache in the groin, lower belly or back is common. Ibuprofen or acetaminophen usually helps. Most men return to desk work within 1 to 2 days.
4. About 1 week
   Avoid heavy lifting, intense exercise and sexual activity for about 5 to 7 days, or as advised. Then resume normal activity.
5. 3–6 months
   If fertility was the reason for treatment, a repeat semen analysis is usually done about 3 months later, and sometimes again at 6 months.

Sometimes the veins in the scrotum feel tender or firm for a couple of weeks as they clot and shrink. This is called phlebitis and settles with anti-inflammatory medicine. The visible swelling usually shrinks slowly over several weeks.

About 9 in 10 men who have embolization for pain notice their pain improve. For men with abnormal semen tests, sperm count and movement improve in many men, and studies of embolization and surgery show similar gains. Treatment raises the chance of natural pregnancy in couples where the man has a varicocele that can be felt and abnormal semen tests, but no treatment can promise a pregnancy.

Embolization does not affect your erections, your ability to ejaculate, or sensation. The testicle keeps its artery and its normal blood supply, because only the faulty vein is closed. Some studies show testosterone levels rise modestly after varicocele treatment, especially in men who started with low levels, but it should not be done for testosterone alone without a careful discussion.

Unlike surgery, embolization almost never causes a hydrocele, a collection of fluid around the testicle, and there is no risk of injuring the testicle's artery.