Varicoceles are enlarged veins that occur in the scrotum. They can be common in adolescent boys and men, with an incidence rate of approximately 15%. Because up to 1/3 of men dealing with infertility have a varicocele, a repair of this venous herniation may be a first line treatment for male fertility. Varicoceles are sometimes referred to as feeling like a "bag of worms" due to the distended veins that coil through the area (the U.S. National Library of Medicine provides a useful illustration). Although varicoceles may be painless, they are thought to be symptomatic in up to 10% of men. Symptoms can be dull, aching, throbbing, and can worsen with physical activity. Conservative care includes scrotal support, limiting physical activity, and using anti-inflammatory medications.
Pelvic rehabilitation providers may work with a male patient who complains of scrotal pain, and who has a known diagnosis of a varicocele. If the patient is unsure of such a diagnosis, questioning the patient about prior discussions with his medical providers may reveal that he was told about “enlarged veins in the scrotum” or similar description. Visual inspection may reveal the tell-tale appearance of distended veins inside the scrotum, and palpation may reveal a significant difference among sides (unless both sides are involved of course.) Physical examination for a varicocele is usually completed in supine and standing positions and may be palpable with or without Valsalva maneuver. Keeping in mind that the differential diagnosis for pain in the scrotum can include medical conditions such as testicular torsion, epididymitis, inguinal hernia, testicular tumor, hydrocele, epididymal cyst, or sperm granuloma, patients who have complaints must see an appropriate medical provider to rule out such conditions. It is also possible for a patient’s condition to change or worsen if a period of time has passed, with communication with the referring provider recommended. Post-surgical complications that should also be considered are inguinal hernia repair for nerve entrapment or vasectomy.
Because of the nerves traveling in the same pathway as the involved veins, we can also consider the neural tension potentially created from the increased venous distension creating either (or both) compression and drag. Surgical options may be discussed by the medical provider, and these might include a microsurgical ligation or a varicolectomy. According to Park & Lee (2013) “A varicocelectomy should be considered in patients with no alleviation of their pain after conservative management, including resting, scrotal elevation, and nonsteroidal anti-inflammatory analgesics.” Conservative management is exactly where we can fit in as providers of pelvic rehabilitation. Including a condition such as a varicocele in our differential diagnosis and treating planning can further our success with patients.
Herman & Wallace offers it's popular Male Pelvic Floor Function, Dysfunction and Treatment course next month in Denver, CO. See you there!
Park, Y. W., & Lee, J. H. (2013). Preoperative predictors of varicocelectomy success in the treatment of testicular pain. The world journal of men's health, 31(1), 58-63.
Shridharani, A., Lockwood, G., & Sandlow, J. (2012). Varicocelectomy in the treatment of testicular pain: a review. Current Opinion in Urology, 22(6), 499-506.