Varicocele

Overview:

• Generally, Testicular veins which drain the testis and epididymis, form multiple veins in the scrotum which are called as pampiniform plexus of veins. Additionally, As they travel the inguinal canal, they are reduced to 6-8 in number. In detail, At the level of deep ring, they are 2 in number and in retroperitoneum, it forms the single testicular vein.
• On the right side, the testicular vein drains into inferior vena cava (in other words, IVC) directly.
• On the left side, it drains into the left renal vein at right angles where there is a valve. [3]
• Besides this, Varicocele is common in tall, thin young men.
• More common on the left side, but often can be bilateral. [5]

Epidemiology:

According to a study published in the Journal of Human Reproductive Sciences in 2013, the prevalence of varicocele in the Indian population ranges from 10% to 20%, affecting a significant portion of adult males.[8]

Causes:

Primary or Idiopathic i.e.:

• Incompetence of valves of the testicular vein
• Common on left side

Secondary i.e.:

• Left sided renal cell carcinoma with a thrombus in left renal vein. [5]

Classification:

1. Firstly, Primary or Idiopathic
2. Secondly, Secondary [5]

Risk factors :

• Age: Varicoceles are most common in men between the ages of 15 and 25.
• Height: Taller men are more likely to develop varicoceles than shorter men.
• Family history: Men with a family history of varicoceles are more likely to develop the condition themselves.
• Obesity: Obesity can increase the pressure in the abdomen, which can lead to the development of varicoceles.
• Occupation: Men who stand for long periods are more likely to develop varicoceles.[9]

Pathogenesis:

• Venous Reflux: The most widely accepted theory behind varicocele formation is the incompetence of venous valves within the spermatic cord. This valvular insufficiency leads to retrograde blood flow (reflux), causing venous dilation and increased pressure within the pampiniform plexus.

• Increased Intratesticular Temperature: The elevated blood volume and stasis associated with varicoceles can disrupt testicular thermoregulation. This results in increased intratesticular temperature, which can negatively impact sperm production and function.

• Oxidative Stress: Varicoceles have been linked to increased oxidative stress within the testes. The excessive production of reactive oxygen species (ROS) can damage sperm DNA and impair their fertilizing capacity.

• Hypoxia: The impaired blood flow in varicoceles can create a hypoxic environment within the testes. This oxygen deprivation can further compromise sperm health and fertility.

• Hormonal Imbalance: Varicoceles may also disrupt the delicate hormonal balance crucial for spermatogenesis. Studies have reported alterations in testosterone and other reproductive hormones in men with varicoceles.[9]

Pathophysiology:

The pathophysiology of varicocele remains incompletely understood, and several theories have been proposed. The most widely accepted theory is that varicoceles result from incompetent or congenitally absent valves in the internal spermatic vein, leading to retrograde blood flow and venous dilatation within the pampiniform plexus. The resulting increase in hydrostatic pressure and blood pooling may impair testicular function through several mechanisms, including increased testicular temperature, hypoxia, and oxidative stress. Additionally, reflux of renal and adrenal metabolites may contribute to testicular damage.[9]

Clinical Features:

• Scrotal Heaviness or Aching: This is often described as a dull, dragging sensation in the affected testicle, typically worsening throughout the day or after prolonged physical activity.
• Visible or Palpable Scrotal Mass: In more advanced cases, the dilated veins may become visible or easily felt upon palpation, particularly when the patient is standing.
• Testicular Atrophy: In some cases, varicoceles can lead to a decrease in testicular size on the affected side.
• Infertility: Varicoceles are associated with impaired sperm quality and can contribute to male infertility.[9]

Sign & Symptoms:

• Swelling in the root of the scrotum
• Dragging pain in the groin also scrotum
• “Bag of worms” feeling
• Impulse specifically, on coughing
• Especially, On lying down it gets reduced (except in renal cell carcinoma) [4]

Clinical / Physical Examination For Varicocele:

• Bow sign: After holding the varicocele between thumb and fingers, patient is asked to bow. In detail, Varicocele gets reduced in size. Bowing reduces the blood flow of testicular vein also pampiniform plexus causing reduction in size. [4]
• On palpation it feels like a ‘bag of worms’. [1]

Diagnosis:

Clinical Examination

• Grading: The severity of varicocele is often graded based on palpation findings:

  • Grade 1: Palpable only during Valsalva maneuver (forced expiration against a closed airway).
  • Grade 2: Palpable without Valsalva but not visible.
  • Grade 3: Visible and palpable.

• Additional Signs: In some cases, the affected testicle may be smaller or softer compared to the unaffected side.

Imaging Studies

• Scrotal Ultrasound: The most commonly used imaging modality, scrotal ultrasound allows for visualization of the dilated veins and assessment of blood flow.

• Other Imaging Modalities: In select cases, additional imaging studies like venography or thermography may be considered.[9]

Differential Diagnosis of Varicocele:

• Hydrocele
• Inguinal hernia
• Lymph varix
• Lipoma of the cord. [4]

Complications :

• Infertility: Varicocele is a leading cause of male infertility, potentially affecting sperm production, motility, and morphology.

• Testicular Atrophy: Reduced blood flow and increased scrotal temperature associated with varicocele can lead to testicular shrinkage and impaired function.

• Pain and Discomfort: While many varicoceles are asymptomatic, some can cause a dull ache or heaviness in the scrotum, particularly after prolonged standing or physical activity.

• Hormonal Imbalance: Varicocele can disrupt the delicate hormonal balance in the testicles, affecting testosterone production and potentially leading to fatigue, decreased libido, and other symptoms.

• Psychological Impact: Concerns about fertility and sexual health can contribute to anxiety and depression in individuals with varicocele.[9]

Investigation of Varicocele:

• Venous Doppler of the scrotum also groin.
• USG abdomen to look for kidney tumours.
• Semen analysis. [4]

Treatment of Varicocele:

• Palomo’s operation i.e.: Suprainguinal extraperitoneal ligation of the testicular vein.
• Inguinal approach i.e.: Easier also safer.
• Scrotal approach i.e.: In case of grade IV, veins have to be excised through this approach
• Laparoscopic approach i.e.: Presently accepted, good approach. [4]

Prevention:

• Lifestyle Factors: Maintaining a healthy lifestyle with regular exercise and a balanced diet may help improve blood circulation and reduce the risk of developing varicocele.
• Avoiding Straining: Activities that involve heavy lifting or straining may increase intra-abdominal pressure and potentially contribute to the development of varicocele.
• Early Detection: Regular self-examinations and seeking medical attention if any scrotal abnormalities are detected can aid in early diagnosis and management of varicocele.[10]

Homeopathic Treatment of Varicocele:

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?.

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. No a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improved with homeopathic medicines.

Homeopathic Medicines for Varicocele:

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

Medicines:

Acidum Flour:

• Moist palms, pain especially in left side.
• Tendency to whitlows fistulae.
• Alopecia, history of syphilis.

Acidum Phos:

• Phosphaturia; additionally pain in testicle.
• Swelling of testes also swelling and tension of spermatic cords.
• Testes tender to touch, either gnawing pain or excoriated feeling in testes.

Aesculus Hip:

• Varicocele from disturbances of portal system with constipation also haemorrhoids.

Aurum:

• Testicles small and weak; in detail indurated.
• Pressive pain when touching or rubbing it.

Hamamelis:

• Drawing pains in testicles night and day.
• Aggravation after midnight till morning, extending from groins.
• Enlargement of spermatic veins, testicle painful, swollen and hard.
• Profuse cold sweat on scrotum; capillary stasis.

Osmium:

• Varicocele produced or aggravated by a deep, hollow, low cough, seemingly coming from low down in the body.

Pulsatilla:

• Especially suitable to fat persons, or those of lax fibre and tearful mood.
• Burning of testicles, without swelling; drawing tensive pains from abdomen through of testicles, without swelling.
• Drawing tensive pains from abdomen through cords into testicles.

Silicea:

• Basically Squeezing pains in testicles.
• Furthermore, Itching humid spots on genitals, mostly on scrotum.
• Sweat-on scrotum.
• Sweaty feet; additionally chilblains.
• Suppression especially of habitual foot-sweat. [6]

Diet & Regimen of Varicocele:

• Eat fresh vegetables and fruits such as beat, cauliflower, broccoli, cucumber, banana, apples, pomegranates, kiwi.
• Other food are wholegrains, olive oil, flaxseed oil, flavonoids.
• Take Plenty of fluid.
• Food to avoid varicocele treatment: caffeine, hydrogenated oil, margarine, sugar, refined white flour, animal fat, alcohol.
• Do Yoga and asanas such as Vajrasan, Dhanurasan, Padmasan and so on. [7]

Do’s & Don’ts :

Varicocele do’s & don’ts 

Do’s:

• Seek medical evaluation: If you notice any scrotal swelling, pain, or discomfort, consult a doctor for proper diagnosis and guidance.
• Wear supportive underwear: An athletic supporter or snug-fitting briefs can help provide support and alleviate discomfort, especially during physical activity.
• Apply cold compresses: Applying ice packs or cold compresses to the scrotum can help reduce swelling and pain.
• Take over-the-counter pain medication: If you experience pain, over-the-counter pain relievers like ibuprofen or acetaminophen can help manage discomfort.
• Consider surgery: If the varicocele causes significant pain, fertility issues, or testicular shrinkage, surgery may be recommended to correct the condition.

Don’ts:

• Ignore symptoms: Don’t dismiss persistent scrotal pain, swelling, or discomfort. Seek medical evaluation for proper assessment.
• Engage in strenuous activity: Avoid heavy lifting or intense physical activity that can worsen discomfort or strain the affected area.
• Wear tight clothing: Tight clothing can restrict blood flow and increase discomfort. Opt for loose-fitting and breathable garments.
• Smoke or consume excessive alcohol: Smoking and excessive alcohol intake can impair blood circulation and potentially worsen varicocele symptoms.
• Self-diagnose or self-treat: Do not attempt to diagnose or treat a varicocele on your own. Consult a doctor for proper evaluation and guidance.

Terminology:

• Varicocele: It is a condition where the veins within the scrotum become enlarged. It is often described as feeling like a "bag of worms."

• Scrotum: This is the pouch of skin that hangs behind the penis. It contains the testicles and other parts of the male reproductive system.

• Testicles: These are the two oval-shaped organs within the scrotum that produce sperm and the male sex hormone testosterone.

• Spermatic Cord: This is a cord-like structure that connects the testicles to the abdomen. It contains blood vessels, nerves, and the vas deferens (the tube that carries sperm from the testicles).

• Pampiniform Plexus: This is a network of veins within the spermatic cord that helps regulate the temperature of the testicles.

• Internal Spermatic Vein: This is the main vein that carries blood away from the testicles.

• Valves: These are small flaps within the veins that help prevent blood from flowing backward.

• Reflux: This is the backward flow of blood within the veins.

• Dilation: This refers to the widening or enlargement of the veins.

• Tortuosity: This refers to the twisting or coiling of the veins.

• Infertility: This is the inability to conceive a child.

• Semen Analysis: This is a laboratory test that evaluates the quality of a man’s semen.

Homoeopathic Terminology:

• Potency: This refers to a homeopathic remedy’s strength or dilution.

• Repertory: This is a reference book that lists homeopathic remedies and their associated symptoms.

• Materia Medica: This is a reference book that provides detailed information about homeopathic remedies, including their sources, preparation, and therapeutic uses.

• Constitutional Remedy: This is a homeopathic remedy that is chosen based on a person’s overall physical, mental, and emotional characteristics.

• Miasm: This is a theoretical concept in homeopathy that refers to an underlying predisposition to disease.

• Aggravation: This is a temporary worsening of symptoms that may occur after taking a homeopathic remedy.

• Ameloriation: This is an improvement in symptoms that may occur after taking a homeopathic remedy.

References:

1. Clinical Surgery S. Das
2.  Bailey_and_Love_s_Short_Practice_of_Surgery
3.  Manipal Manual of Surgery (PDF Drive)
4.  SRB_s Manual of Surgery, 3rd Edition
5.  SRB’s Clinical Methods in Surgery
6.  Homeopathic Therapeutics by Lilienthal
7.  https://nirogamonline.com/blogs/articles/how-to-cure-varicocele-with-yoga-and-diet
8. Journal of Human Reproductive Sciences in 2013.

9. Campbell-Walsh Urology, 12th Edition

10. Smith’s General Urology (18th Edition)

Also Search As:

Online search engines:

• General search engines like Google, Bing, DuckDuckGo: Use search terms like "homeopathy varicocele treatment", "homeopathic remedies for varicocele", or "varicocele homeopathic articles". You can also try adding specific keywords like "research", "case studies", or "clinical trials" to narrow your results.
• Specialized search engines for scientific literature: Consider using resources like PubMed or Google Scholar to find peer-reviewed research articles on homeopathy and varicocele.

Homeopathic websites and databases:

• Websites of homeopathic organizations: National or international homeopathic organizations often have resources and articles available on their websites.
• Online homeopathic libraries and databases: Several online libraries and databases specialize in homeopathic literature.

Social Media and Online Forums:

• Social media platforms: Follow homeopathic practitioners, researchers, or organizations on platforms like Facebook, Twitter, or LinkedIn to stay informed about the latest news and articles related to homeopathy and varicocele.
• Online forums and discussion groups: Participate in online communities focused on homeopathy to ask questions and learn from others’ experiences.

Search Engines

• Google/Bing/DuckDuckGo:
  
  • Simple search: "varicocele"
  • Specific searches:
    
    • "varicocele treatment options"
    • "varicocele and infertility"
    • "varicocele surgery complications"
  • Use advanced search operators:
    
    • "varicocele" filetype:pdf (to find research articles in PDF format)
    • "varicocele" site:.edu (to limit results to educational websites)

Academic Databases:

• PubMed: A primary source for biomedical and life science research literature. It’s great for finding peer-reviewed studies and clinical trials.   
• Google Scholar: Provides a broader range of scholarly literature, including articles, theses, and books.   

Medical Websites and Organizations:

• Mayo Clinic: Reputable source for patient education materials on varicocele.
• American Urological Association: Offers information on varicocele and related conditions, as well as guidelines for treatment.