TreasureVibe
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For a long while I've been trying to figure out what the exact background of varicocele is since I suffer it myself. I always thought that surgery was invasive and that cutting the spermatic vein is a one-way road. This is how the surgical procedure is done, after which the two sides of the vein are tied off. The reports on the material used in some coils for the alternative of surgery, varicocele embolization, causing cancer aren't making me excited either.
The consensus on what the cause of varicocele is according to urologists universally is defective valves, notably defective valves right above the pampiniform plexus.
Now I have come across a study that confirms what I have been thinking all along, that this theory is wrong. In-fact, this recent study proves that veins are not a causative factor at all, as it shows healthy veins with absence of any valves.
https://www.researchgate.net/publication/287626428_Valves_of_the_gonadal_veins
Purpose: Varicocele seems not to rely on the number of valves within the pampiniform plexus, the initial failure might be located on a higher level. Therefore, the failure should also occur in females. There is a comparable disease, Pelvic congestion syndrome, as result of pelvic venous engorgement due to gross dilatation and incompetence of ovarian veins. Thus, we need a detailed description of venous course, branching as well as frequencies and locations of valves within both genders. Page 3/23 Material and Methods: In 31 Caucasian formalin-fixed bodies (15 males, 16 females) we investigated course and valves from Ovaries or internal inguinal ring, respectively, up to termination into inferior vena cava or left renal vein, respectively. Specimens were documented photographically and by a distinct protocol. Results: In general, we found one valve on each side (testicular vein right 41.93%, left 51.52%; ovarian vein right 51.61%, left 45.45%). Two specimens had two valves per vein, each in a left testicular vein, and 15 veins showed absent valves. Valves existed between 0.0-4.5 cm, mainly 0.0-1.0 cm. One corpse showed varicose ovarian veins. Conclusion: If veins show varices, one would expect missing valves or insufficient function. In contrast, none of our 15 valve-less veins showed varices or even enlargement. Also surprising, the only case with varices had one valve on each side. The terminal segment in both genders was almost identical and the venous course was similar. Precisely: men frequently had (N=11) less valves then women (N=4).
Now a very important nuance that is still missed in the medical field and research today that I picked out of this study is that pelvic congestion syndrome and varicocele are the exact same thing.
In females it is often called pelvic congestion syndrome and ovarian vein reflux and in men almost always varicocele. In both men and women however, the clinical presentation is exactly the same. This leads me to believe that the cause in female and male are the same too.
In-fact, multiple medical sources mention that varicocele is the same condition as pelvic congestion syndrome. An academic example of this is Professor Mark Whiteley MBBS MS FRCS, a renown venous surgeon and phlebologist from the United Kingdom who is also the founder of the Whiteley Clinic which specializes in varicose veins treatment. He mentions this in the following presentation:
The following medical source also mentions varicocele as the same thing as pelvic congestion syndrome:
Pelvic Congestion Syndrome
As well as this New York City based clinic which specializes in pelvic congestion syndrome, mentioning it treats both men and women for the condition:
Pelvic Congestion Syndrome (PCS) - Pamela Morrison Pelvic Pain Physical Therapist, P.C.
With that being said, the realization that pelvic congestion syndrome and varicocele are one in the same, opens up a big stockpile of literature and research for the average varicocele investigator like me. Searching for "pelvic congestion" on PubMed alone finds you 503 studies and "ovarian vein reflux" 65 studies. Searching for "pelvic congestion syndrome" finds you 303 studies. Pelvic congestion syndrome also has some confirmed causes: Nutcracker syndrome, May-Thurner syndrome and Budd-Chiari syndrome and external compression due to tumor (including fibroid, endometriosis) or scarring.
Furthermore, I would like to expand on Nutcracker syndrome as being a cause for varicocele, much more often than previously thought. This 2010 study describes the following:
Varicocele and nutcracker syndrome: sonographic findings. - PubMed - NCBI
OBJECTIVE: Varicocele is a vascular lesion commonly associated with infertility. Its etiology is only partly understood; hence, the purpose of the study was to establish its correlation with intrinsic anatomic differences and nutcracker syndrome.
METHODS: A total of 93 patients with varicocele and 76 patients without varicocele were enrolled. The diagnosis of varicocele was based on physical examination, followed by sonographic evaluation of the hilar portion and aortomesenteric portion (AMP) of the left renal vein (LRV). The anteroposterior diameter in millimeters and peak flow in centimeters per second in each region were measured.
RESULTS: A total of 28 patients with the nutcracker syndrome were identified in the study group (30.10%), and 2 were identified in the control group (2.63%). The mean diameters of the hilar portion and AMP of the LRV were significantly different in varicocele-affected patients compared with the control group (P < .0001 for both). The mean peak velocities in the hilar portion and AMP were significantly different in patients with varicocele (P < .0001). Patients with varicocele and nutcracker syndrome did not have a significant difference in either the hilar or AMP diameter compared with patients with varicocele without nutcracker syndrome. They had a significant difference in both the hilar and AMP peak flow velocity (P = .0001 for both).
CONCLUSIONS: Our findings indicate that nutcracker syndrome is a frequent finding in varicocele-affected patients and should be routinely excluded as a possible cause of varicocele. In addition, intrinsic anatomic differences in the AMP and hilar portion of the LRV could be directly responsible for the onset of varicocele.
As a footnote I would like to add the following segment of a 2015 study on varicocele in regards to valves not being the cause which further ties into the aforementioned studies:
Varicocele and testicular function
...First, venous valves are more commonly absent on the left-side, with one study finding valves absent in 40% of left spermatic veins, but absent in only 23% of right spermatic veins.11However, 26% of patients with varicocele have competent valves, making the absence of valves an unlikely unifying cause of varicocele.12...
A male friend of mine with varicocele had two MRIs done, one on his pelvis and one on his lumbrosacral spine. The results were noted as the following:
"Extensive bilateral varicoceles extending into the pelvis and bilateral pelvic sidewall.”
"Note is made of prominent pelvic veins. Engorgement of the seminal vesicles and tubules."
Not surprisingly, these findings are identical to the findings on a MRI of a female with pelvic congestion syndrome in regards to the tubules:
Source: Pelvic Congestion Syndrome | Vein Treatment Center
Furthermore, a professional of the Sheen Vein Institute says the following:
Do you have information on the use/effectiveness of physical therapy with pelvic congestion syndrome? - Pelvic Congestion Syndrome Treatment Questions & Answers
"Answered by The Sheen Vein Institute
Pelvic congestion syndrome is due to the presence of varicose veins inside the pelvic cavity. The result is congestion and often discomfort due to the pressure and irritation in that area."
This leads me to believe there is a possible cause found for PCS/varicocele in the pelvic floor. Upon further investigation I found out that the diaphragm is connected to the pelvic floor physically, by the following presentation:
After trying out diaphragmatic breathing while standing, especially holding in my breath, I discovered it makes the varicocele disappear for 90 to 98%. I previously already knew that a squat called Malasana, hindi squat or Garland pose makes my varicocele disappear for 100%, and stretch exercises for the adductor muscles also make my varicocele dissapear 100%. This is probably due to the stretching effect on the pelvic floor muscles. I had a slower urinary flow for a year and a half after I developed varicocele, and this is caused by the pelvic floor muscles too:
UCSF Department of Urology | Female Voiding Dysfunction
All in all my suspicions that the pelvic floor muscles are the root cause of varicocele/PCS are highly supported by the previous findings and another cause in a lot of cases would be Nutcracker syndrome with these two causes as the most common causes, the pelvic floor muscles being the most. A role for another muscle or muscle group like the psoas muscles, shown in an anatomical variant to have the spermatic vein run through it, being the cause is not ruled out. The other fewer causes would be the syndromes named earlier and cancer, Cysts and scarring. The urologists consensus that defective valves are the cause is unsupported by scientific evidence.
The consensus on what the cause of varicocele is according to urologists universally is defective valves, notably defective valves right above the pampiniform plexus.
Now I have come across a study that confirms what I have been thinking all along, that this theory is wrong. In-fact, this recent study proves that veins are not a causative factor at all, as it shows healthy veins with absence of any valves.
https://www.researchgate.net/publication/287626428_Valves_of_the_gonadal_veins
Purpose: Varicocele seems not to rely on the number of valves within the pampiniform plexus, the initial failure might be located on a higher level. Therefore, the failure should also occur in females. There is a comparable disease, Pelvic congestion syndrome, as result of pelvic venous engorgement due to gross dilatation and incompetence of ovarian veins. Thus, we need a detailed description of venous course, branching as well as frequencies and locations of valves within both genders. Page 3/23 Material and Methods: In 31 Caucasian formalin-fixed bodies (15 males, 16 females) we investigated course and valves from Ovaries or internal inguinal ring, respectively, up to termination into inferior vena cava or left renal vein, respectively. Specimens were documented photographically and by a distinct protocol. Results: In general, we found one valve on each side (testicular vein right 41.93%, left 51.52%; ovarian vein right 51.61%, left 45.45%). Two specimens had two valves per vein, each in a left testicular vein, and 15 veins showed absent valves. Valves existed between 0.0-4.5 cm, mainly 0.0-1.0 cm. One corpse showed varicose ovarian veins. Conclusion: If veins show varices, one would expect missing valves or insufficient function. In contrast, none of our 15 valve-less veins showed varices or even enlargement. Also surprising, the only case with varices had one valve on each side. The terminal segment in both genders was almost identical and the venous course was similar. Precisely: men frequently had (N=11) less valves then women (N=4).
Now a very important nuance that is still missed in the medical field and research today that I picked out of this study is that pelvic congestion syndrome and varicocele are the exact same thing.
In females it is often called pelvic congestion syndrome and ovarian vein reflux and in men almost always varicocele. In both men and women however, the clinical presentation is exactly the same. This leads me to believe that the cause in female and male are the same too.
In-fact, multiple medical sources mention that varicocele is the same condition as pelvic congestion syndrome. An academic example of this is Professor Mark Whiteley MBBS MS FRCS, a renown venous surgeon and phlebologist from the United Kingdom who is also the founder of the Whiteley Clinic which specializes in varicose veins treatment. He mentions this in the following presentation:
The following medical source also mentions varicocele as the same thing as pelvic congestion syndrome:
Pelvic Congestion Syndrome
As well as this New York City based clinic which specializes in pelvic congestion syndrome, mentioning it treats both men and women for the condition:
Pelvic Congestion Syndrome (PCS) - Pamela Morrison Pelvic Pain Physical Therapist, P.C.
With that being said, the realization that pelvic congestion syndrome and varicocele are one in the same, opens up a big stockpile of literature and research for the average varicocele investigator like me. Searching for "pelvic congestion" on PubMed alone finds you 503 studies and "ovarian vein reflux" 65 studies. Searching for "pelvic congestion syndrome" finds you 303 studies. Pelvic congestion syndrome also has some confirmed causes: Nutcracker syndrome, May-Thurner syndrome and Budd-Chiari syndrome and external compression due to tumor (including fibroid, endometriosis) or scarring.
Furthermore, I would like to expand on Nutcracker syndrome as being a cause for varicocele, much more often than previously thought. This 2010 study describes the following:
Varicocele and nutcracker syndrome: sonographic findings. - PubMed - NCBI
OBJECTIVE: Varicocele is a vascular lesion commonly associated with infertility. Its etiology is only partly understood; hence, the purpose of the study was to establish its correlation with intrinsic anatomic differences and nutcracker syndrome.
METHODS: A total of 93 patients with varicocele and 76 patients without varicocele were enrolled. The diagnosis of varicocele was based on physical examination, followed by sonographic evaluation of the hilar portion and aortomesenteric portion (AMP) of the left renal vein (LRV). The anteroposterior diameter in millimeters and peak flow in centimeters per second in each region were measured.
RESULTS: A total of 28 patients with the nutcracker syndrome were identified in the study group (30.10%), and 2 were identified in the control group (2.63%). The mean diameters of the hilar portion and AMP of the LRV were significantly different in varicocele-affected patients compared with the control group (P < .0001 for both). The mean peak velocities in the hilar portion and AMP were significantly different in patients with varicocele (P < .0001). Patients with varicocele and nutcracker syndrome did not have a significant difference in either the hilar or AMP diameter compared with patients with varicocele without nutcracker syndrome. They had a significant difference in both the hilar and AMP peak flow velocity (P = .0001 for both).
CONCLUSIONS: Our findings indicate that nutcracker syndrome is a frequent finding in varicocele-affected patients and should be routinely excluded as a possible cause of varicocele. In addition, intrinsic anatomic differences in the AMP and hilar portion of the LRV could be directly responsible for the onset of varicocele.
As a footnote I would like to add the following segment of a 2015 study on varicocele in regards to valves not being the cause which further ties into the aforementioned studies:
Varicocele and testicular function
...First, venous valves are more commonly absent on the left-side, with one study finding valves absent in 40% of left spermatic veins, but absent in only 23% of right spermatic veins.11However, 26% of patients with varicocele have competent valves, making the absence of valves an unlikely unifying cause of varicocele.12...
A male friend of mine with varicocele had two MRIs done, one on his pelvis and one on his lumbrosacral spine. The results were noted as the following:
"Extensive bilateral varicoceles extending into the pelvis and bilateral pelvic sidewall.”
"Note is made of prominent pelvic veins. Engorgement of the seminal vesicles and tubules."
Not surprisingly, these findings are identical to the findings on a MRI of a female with pelvic congestion syndrome in regards to the tubules:
Source: Pelvic Congestion Syndrome | Vein Treatment Center
Furthermore, a professional of the Sheen Vein Institute says the following:
Do you have information on the use/effectiveness of physical therapy with pelvic congestion syndrome? - Pelvic Congestion Syndrome Treatment Questions & Answers
"Answered by The Sheen Vein Institute
Pelvic congestion syndrome is due to the presence of varicose veins inside the pelvic cavity. The result is congestion and often discomfort due to the pressure and irritation in that area."
This leads me to believe there is a possible cause found for PCS/varicocele in the pelvic floor. Upon further investigation I found out that the diaphragm is connected to the pelvic floor physically, by the following presentation:
After trying out diaphragmatic breathing while standing, especially holding in my breath, I discovered it makes the varicocele disappear for 90 to 98%. I previously already knew that a squat called Malasana, hindi squat or Garland pose makes my varicocele disappear for 100%, and stretch exercises for the adductor muscles also make my varicocele dissapear 100%. This is probably due to the stretching effect on the pelvic floor muscles. I had a slower urinary flow for a year and a half after I developed varicocele, and this is caused by the pelvic floor muscles too:
UCSF Department of Urology | Female Voiding Dysfunction
All in all my suspicions that the pelvic floor muscles are the root cause of varicocele/PCS are highly supported by the previous findings and another cause in a lot of cases would be Nutcracker syndrome with these two causes as the most common causes, the pelvic floor muscles being the most. A role for another muscle or muscle group like the psoas muscles, shown in an anatomical variant to have the spermatic vein run through it, being the cause is not ruled out. The other fewer causes would be the syndromes named earlier and cancer, Cysts and scarring. The urologists consensus that defective valves are the cause is unsupported by scientific evidence.
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