‘Warming worms’ and dwindling drive

Dear Dr G,

I am a 30-year-old man deeply troubled by testicular problems and the associated dwindling libido.

My wife and I were married just before the pandemic.

Just like many others, we led a sedentary life during the lockdown, resulting in expanding waistlines.

As my weight increased, I also noticed a constant dragging sensation on my left testicle, accompanied by intermittent swelling that resembled worms.

I was not at all alarmed as I read in your previous articles that this is associated with varicose veins.

Truthfully, I am not particularly bothered by the swelling and the dragging sensation on the scrotum. However, I am somewhat perturbed by the associated sexual dysfunction.

I started off having groin discomfort during sexual intercourse, and also notice my sex drive has dwindled over the last few months.

Sadly, in addition to the above, I also began to experience weakening erection.

I went to a urologist who confirmed varicocele (enlargement of veins within the scrotum) and reckoned my sexual dysfunction is associated with declining testosterone owing to the warming testicles.

In fact, the doctor suggested corrective operations to resolve my dragging scrotum and dwindling drive.

Before I embark on any treatment, I would like to put Dr G on the spot for some clarification.

Can you tell me how exactly does one get varicocele?

Is it associated with sexual dysfunction? If so, what is the mechanism of association?

Apart from sexual dysfunction, how else can varicocele affect my life?

Lastly, tell me about the corrective surgery, and if I should go for it.

Regards,

Dragging Dave

A varicocele is an abnormal enlargement of the veins, known as the pampiniform venous plexus, within the loose bag of skin that holds the testicles. The testicular arteries perfuse the testicles and transfer blood through the plexus of veins that carry it back to the body.

Excess stagnating blood can result in dilations of these vessels. In other words, it is like the varicose veins of the legs, as excess blood can also accumulate in the scrotum.

Varicocele is more common on the left side than the right, as the venous drainage system on the left will drain blood via the renal vein before returning to inferior vena cava. The exact etiology of varicocele is unknown. Three main theories have been proposed as the anatomical cause.

The first is the geometry of the veins, wherein the vein on the left side connects to the larger outflowing vein at a right angle, resulting in venous dilations. The second is the venous insufficiency of the valves of these veins, resulting in constant backflow of the blood.

The third is excessive pressure in upstream arteries, created by “nutcracker syndrome” (a rare disorder when certain arteries squeeze the left renal or kidney vein). Varicocele is common as it affects around 15% to 20% of all adult males. Up to 35% to 40% of men who are evaluated for male infertility are also noted to have varicocele.

It is believed the warming effect from the dilated veins may have an adverse impact on spermatogenesis, resulting in a decrease in sperm quality. Varicocele is often asymptomatic and most patients are oblivious to it. However, it may be noticed as soft lumps, usually above the testicle, and present as heaviness in the scrotum. Larger varicocele may even be described as a bag of worms in the sac.

The severity of varicocele can be graded from 1 to 3. Grade 1 is generally visible only on straining, while grade 3 is clearly visible when standing. Although the adverse association of varicocele with reproductive health is established, the correlation between varicocele and sexual dysfunction is not well studied.

One study from Taiwan used data from the Longitudinal Health Insurance Database 2000, with a total of 32,856 cases and 98,568 randomly selected controls. Statistical analyses were used to examine associations between erectile dysfunction (ED) and having been previously diagnosed with varicocele or undergoing a varicocelectomy.

The study highlighted a threefold increase of ED in men with varicoceles. Other smaller studies also revealed men experiencing pain on intercourse and dwindling libido, directly and indirectly linked to varicocele.

The treatment of varicocele is only necessary in men who experience discomfort or inability to father a child. The mechanism of treatment is to ligate the dilated vessels and divert blood flow through other channels. Such surgical intervention can be an open operation, laparoscopic intervention, or percutaneous embolisation. Varicocele operations are generally safe, but adversities such as infections, fluid collection, recurrence and even damage to the artery have been reported.

Varicocelectomy is known to improve semen quality in 60% to 80% of men and the improvement of fertility can range from 43% to 69% over two-year intervals.

The publications revealed most improvement in semen quality and pregnancy are mostly noted in repairs for more severe varicocele. However, there is no study demonstrating reversal of sexual function following the correction of varicocele.

For varicocele sufferers facing “warming worms” in the sac, evidence is mounting that dwindling sex drive and male infertility are potentially on the horizon. When put on the spot for an opinion about treatment and corrective surgery, Dr G’s view is that doing nothing will only diminish your fertility and chances for improvement in sexual performance.