What is varicocele

Varicoceles are varicose veins or swelling of the veins inside your scrotum (pampiniform plexus veins in the scrotum become enlarged) ¹. Varicoceles form in the veins that run along the spermatic cord (the cord that holds up a man’s testicles). Blood from the testicles flows back into the body through those veins. Like varicose veins in the legs, varicoceles form when blood builds up in the veins and they become permanently enlarged.

Varicoceles are common in prepubescent and adolescent boys. About 10 to 15 boys out of 100 have a varicocele ². Varicoceles are uncommon in boys younger than age 10 and rarely develop after adolescence. Most varicoceles are found only on the left side because of the way blood drains from the left testicle ³. In some cases varicoceles can also develop above the right or in both testicles, but this is rare ².

Varicoceles are more common in men ages 15 to 25 and are most often seen on the left side of the scrotum. About 15 out of 100 men have varicoceles. It’s hard to predict which of these 15 will have fertility problems caused by their varicocele. But about 4 in every 10 men tested for fertility problems have a varicocele and decreased sperm movement. There’s no link with other defects, race, place of birth, or ethnic group. Although varicoceles are often found in men tested for infertility, 8 out of 10 men who have a varicocele don’t have fertility problems.

Varicoceles usually are not painful and do not need treatment. However, treatment might be advised if a varicocele:

• Is painful
• Causes a testicle to under develop or shrink (testicular hypotrophy)
• Potentially affects the ability to father children (fertility)

Some varicoceles may cause infertility (problems fathering a child) and slow growth of the left testicle during puberty. Varicoceles may be the cause of fertility problems in about 4 out 0f 10 men who have problems fathering their first child. Varicoceles may also be the cause of fertility problems in about 8 out of 10 men who have problems fathering a child after their first.

Varicoceles can affect fertility by reducing blood flow and raising the temperature of the testicles ³. This can cause the testicles to produce fewer sperm, and sperm that is produced might not be healthy. Early treatment can help produce healthier sperm and even regrowth of a testicle.

Figure 1. Testicle anatomy

Figure 2. Varicocele (varicoceles are usually found in the left side of the scrotum)

What will happen if I choose not to get treated?

Not treating a varicocele may result in the testicle shrinking and/or a drop in semen quality. This may lead to fertility problems, though this is rare. The varicocele may, over time, cause lasting harm to the testicle that can’t be fixed. If a semen analysis is normal, then it’s okay not to get treated. If the semen analysis isn’t normal, then action is called for. In some men, the “varicocele effect” on making sperm may get worse over time. Fertility issues may come up years later, even if not seen earlier.

My teenage son was diagnosed with a varicocele. Should this be fixed?

Treatment of teenagers depends on each case. It’s important to discuss options with a urologist or pediatric urologist. Varicocele repair in a teen may be considered if there is pain or if 1 testicle is more than 10% smaller than the other. Some families choose repair so they won’t have to worry about fertility issues in the future. Semen analyses can be done in older teens to see if repair would help.

I’m interested in having children and have no symptoms. Should I have my varicocele repaired?

As a rule, varicoceles with no symptoms aren’t repaired. Most health care providers don’t believe these varicoceles cause health problems if not treated. If there’s worry about fertility, semen analysis can be done to see if the varicocele is harming sperm quality.

I have pain with my varicocele. What can I do to ease the pain?

Supporting the scrotum with a jockstrap or briefs-style underwear can help varicocele pain. Lying on your back helps the varicocele drain, and often eases pain. Taking pain killers (such as acetaminophen and ibuprofen) may also help. You can also talk with your urologist about varicocele repair.
I’m thinking about having my varicocele repaired for fertility reasons. How long will I have to wait to see if my semen quality improves?

Semen analyses are often done every 3 to 4 months after the procedure. Improvement is often seen within 6 months, but might take a year.

I found a lump on my scrotum during a self-exam. Should I worry?

Abnormalities in the male reproductive tract may show up as a mass in the scrotum. Masses could be nothing to worry about and have little effect on your health. Or they could be a sign of life-threatening illness. It’s important to find out what is causing your mass. For example, testicular cancer is cause for concern and calls for prompt action. It’s important to seek medical attention when you find any lump or bump in your testicle.

Varicocele severity grade

The severity of a varicocele can be classified into three grades:

1. Can be felt by hand only during straining
2. Can be felt by hand when relaxed
3. Can become clearly visible at a distance, even at complete rest.

What causes varicocele

It is not known why varicoceles develop. They may be associated with accelerated sexual organ growth in young boys, but no specific risk factors have been determined. A varicocele forms when valves inside the veins that run along the spermatic cord prevent blood from flowing properly. Blood backs up, leading to swelling and widening of the veins. Also, the larger veins moving from the testicles towards the heart are connected differently on the left and right side. So more pressure is needed on the left side to keep blood flowing through the veins towards the heart. If blood flows backwards or pools in the veins, that can cause them to swell. This is similar to varicose veins in the legs.

Rarely, swollen lymph nodes or other abnormal masses behind the abdomen block blood flow. This can lead to sudden swelling of the scrotal veins. This is often painful.

Most of the time, varicoceles develop slowly.

A varicocele in an older man that appears suddenly may be caused by a kidney tumor, which can block blood flow to a vein.

Varicocele symptoms

Most males with a varicocele have no symptoms.

Varicoceles usually have no symptoms. In rare cases, it may cause pain, which may:

• Vary from sharp to dull discomfort in the scrotum
• Increase with standing or physical exertion
• Worsen over the course of the day
• Be relieved when you lie on your back

Varicocele signs include:

• Enlarged, twisted veins in the scrotum
• Painless testicle lump, scrotal swelling, or bulge in the scrotum
• Possible problems with fertility or decreased sperm count.

With time, varicoceles might enlarge and become more noticeable. A varicocele has been described as looking like a “bag of worms.” The condition might cause a swollen testicle, almost always on the left side.

You may notice a varicocele, or it may be noticed by your parents or by a physician during a routine physical examination or during a fertility evaluation at an older age.

Varicocele possible complications

Infertility is a complication of varicocele.

A varicocele may cause:

• Shrinkage of the affected testicle (atrophy). Most of the testicle is made up of sperm-producing tubules. When they are damaged, as from a varicocele, the testicle shrinks and softens. It is not clear what causes the testicle to shrink, but the malfunctioning valves allow blood to pool in the veins. This pooling can result in increased pressure in the veins that may cause testicular damage.
• Problems fathering children (infertility). With a varicocele, the testicle may be too warm. This can affect sperm formation, movement (motility), and function.

Complications from treatment may include:

• Atrophic testis
• Blood clot formation
• Infection
• Injury to the scrotum or nearby blood vessel

Varicocele diagnosis

It is usually relatively simple to diagnose a varicocele. Your doctor will take a detailed medical history and ask questions about your symptoms, if any.

You will have an exam of your groin area, including the scrotum and testicles. A collection of swollen and tangled veins in the scrotum that can be felt more in the upright posture or during straining, suggests a varicocele. The swollen veins may feel like a “bag of worms”. Both testicles should be examined to compare their size. The testicle on the side of the varicocele may be smaller than the one on the other side.

Sometimes the growth may not be able to be seen or felt, especially when you are lying down.

You may also have an ultrasound of the scrotum and testicles, as well as an ultrasound of the kidneys.

Backward flow of blood in the swollen testicular veins is usually confirmed by ultrasound of the scrotum. Signs of varicoceles on ultrasound are veins that are wider than 3 millimeters with blood flowing the wrong way during the Valsalva maneuver. The ultrasound can also show the size of the testicles. These are useful in deciding how to treat teenagers. An ultrasound isn’t needed if no problems are felt during the physical exam.

A right-side-only varicocele is uncommon. In extremely rare cases, it might be caused by a tumor of the kidney. Ultrasound of the kidneys should be performed to rule it out.

Varicocele treatment

Often, varicoceles are not treated. A jock strap or snug underwear may help ease discomfort. You may need other treatment if the pain does not go away or you develop other symptoms.

Surgery is the only way to treat varicoceles, but not all patients would benefit from surgery. Your doctor may recommend surgery if:

• The affected testicle is small
• Fertility is or could be affected
• Varicocele is present in both testicles
• The sperm is not healthy (in older adolescents)
• Pain, marked swelling, or physical discomfort is present

If none of these criteria apply to you, surgery is not needed. You should visit your doctor annually until sperm can be analyzed.

Boys with a smaller left testicle are thought to have a higher risk for fertility problems when they get older.

There are no drugs to treat or prevent varicoceles. But pain killers (such as acetaminophen or ibuprofen) may help with pain.

Varicocele surgery

There are many ways to do varicocele surgery. All involve blocking the blood flow in the pampiniform plexus veins.

The surgical procedure blocks the enlarged veins from draining blood from the testicle. This blockage redirects the blood flow to healthy veins.

During surgery, your doctor will try to protect nearby structures called lymphatic vessels. These tiny structures are usually invisible to the naked eye. They carry lymph, a clear, yellowish liquid that collects in all parts of the body. If they are injured, lymph cannot flow properly, and complications can develop. This surgery, called lymphatic-sparing varicocelectomy , can lower the chance of complications.

Surgery to correct a varicocele is called varicocelectomy. For this procedure:

• You will receive some type of numbing medicine (anesthesia).
• The urologist will make a small cut with the use of a surgical microscope, most often in the lower abdomen, and tie off the abnormal veins. This directs blood flow in the area to the normal veins. The operation may also be done as a laparoscopic procedure (through small incisions with a camera).
• You will be able to leave the hospital on the same day as your surgery.
• You will need to keep an ice pack on the area for the first 24 hours after surgery to reduce swelling.

Open Surgery

• Open surgery repair is done through a single 1 inch cut. The surgeon may use a magnifying glass or operating microscope to see small veins. The surgery can be done under local or general anesthesia.

This treatment usually is done on an outpatient basis, during general or local anesthetic. Commonly, your surgeon will approach the vein through your groin (inguinal or subinguinal), but it’s also possible to make an incision in your abdomen or below your groin.

Advances in varicocele repair have led to a reduction of post-surgical complications. One advance is the use of the surgical microscope, which enables the surgeon to see the treatment area better during surgery. Another is the use of Doppler ultrasound, which helps guide the procedure.

You might be able to return to normal, nonstrenuous activities after two days. As long as you’re not uncomfortable, you might return to more strenuous activity, such as exercising, after two weeks.

Pain from this surgery generally is mild but might continue for several days or weeks. Your doctor might prescribe pain medication for a limited period after surgery. After that, your doctor might advise you to take over-the-counter painkillers, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others) to relieve discomfort.

Your doctor might advise you not to have sex for a period of time. Most often, it will take several months after surgery before improvements in sperm quality can be seen with a semen analysis. This is because it takes approximately three months for new sperm to develop.

Open surgery using a microscope and subinguinal approach (microsurgical subinguinal varicocelectomy) has the highest success rates when compared with other surgical methods.

Laparoscopic Surgery

• Laparoscopic surgery is done through thin tubes put into your body through a small cut. The surgeon uses a special camera to see inside your body.
• Laparoscopic surgery is done under general anesthesia.

What are the most common complications after surgery?

• Collection of fluid in the scrotum around the testicle (hydrocele formation)
• Shrinking of the testicle (testicular hypotrophy)
• Reduced function of the testicle
• Injury to the testicular artery
• Varicocele remaining (persistence) or coming back (recurrence)

There is a small chance surgery won’t correct the problem. In rare cases, injury to the testicular artery can lead to loss of the testicle. Persistence or recurrence of the varicocele happens in fewer than 1 of 10 patients who have surgery. Open surgery done with magnification has a low persistence rate or chance of varicocele coming back.

Recovery after surgery

Since surgeons have started using smaller cuts through the muscle for open surgery, healing time and pain are about the same with open and laparoscopic surgery.

You may be able to return to normal, nonstrenuous activities after 2 days. As long as you’re not uncomfortable, you may return to more strenuous activity, such as exercising, after 2–4 weeks.

Pain from this surgery is usually mild but may continue for several days or weeks. Your doctor may prescribe pain medication for a limited time after surgery. After that, your doctor may advise you to take over-the-counter medication like acetaminophen or ibuprofen. Wearing briefs or a jockstrap can also help by relieving pressure in the testicles.

It will take several months after surgery before improvements in sperm quality can be seen with a semen analysis, semen analysis is done 3 to 4 months later. This is because it takes approximately 3 months for new sperm to develop.

Follow up with your doctor if you have questions or concerns.

Varicocele embolization

Less often, a procedure called angiographic occlusion or varicocele embolization is used to treat varicocele. Embolization is done by a radiologist. Varicocele embolization collapses the twisted vein with a special substance. This method does not usually require you to be asleep (general anesthesia) and is less invasive than laparoscopic surgery. However, it uses X-ray, so you are exposed to radiation.

For varicocele embolization procedure:

• Percutaneous embolization is most often done with general anesthesia. It often takes several hours.
• A small hollow tube called a catheter (tube) is placed into a vein in your groin or neck area.
• Your doctor moves the tube into the varicocele using x-rays as a guide.
• A tiny coil passes through the tube into the varicocele. The coil blocks blood flow to the bad vein and sends it to normal veins.
• You will need to keep an ice pack on the area to reduce swelling and wear a scrotal support for a little while.

This method is also done without an overnight hospital stay. It uses a much smaller cut than surgery, so you will heal faster.

Some problems with varicocele embolization are:

• varicocele remaining (persistence) or coming back (recurrence)
• the coil moving from where it was placed
• a chance of infection where the tube was placed

Recovery after embolization

Healing after embolization is also relatively short with only mild pain. You should avoid exercise for 7 to 10 days after the procedure. You can often return to work 1 or 2 days later. The recurrence rate with embolization is often higher than with surgery. But there are cases where embolization is preferred over surgery.

Varicocele prognosis

A varicocele is often harmless and often does not need to be treated, unless there is a change in the size of your testicle.

If you have surgery, your sperm count will likely increase. However, it will not improve your fertility. In most cases, testicular wasting (atrophy) does not improve unless surgery is done early in adolescence.

The impact of varicocele repair on fertility isn’t clear. Some studies show fertility improves after varicocele repair while other studies don’t. Semen quality improves in about 6 out of 10 infertile men after varicocele repair. This treatment should be considered along with other fertility treatment choices.

In teens, where the main reason for surgery is slow testicular growth, catch-up growth occurs in 8 out of 10 patients.

1. Informed Health Online [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Varicoceles: Overview. 2009 Aug 7 [Updated 2016 Jun 1]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279346[↩]
2. What are Varicoceles?  https://www.urologyhealth.org/urologic-conditions/varicoceles[↩][↩]
3. Varicocele. https://patients.uroweb.org/varicocele/[↩][↩]

What is Ludwig’s angina

Ludwig’s angina is a type of bacterial infection that occurs in the floor of the mouth, under the tongue. Ludwig angina often develops after an infection of the roots of the teeth (such as tooth abscess) or a mouth injury. Ludwig’s angina can be life threatening. Prior to the development of antibiotics, mortality exceeded 50% ¹. With antibiotic therapy, along with improved imaging modalities and surgical techniques, mortality is approximately 8% ¹.

Ludwig angina can be cured with getting treatment to keep the airways open and taking antibiotic medicine.

Ludwig’s angina was named after a German physician, Wilhelm Friedrich von Ludwig who first described the condition in 1836 ¹. Ludwig’s angina involves two compartments on the floor of the mouth namely sublingual and submaxillary space. Ludwig’s angina usually does not involve lymphatic system nor it forms abscess. Infection of the lower molars is the most common cause of Ludwig’s angina. The infection is rapidly progressive leading to aspiration pneumonia and airway obstruction.

Ludwig angina is uncommon in children.

If the swelling blocks your airway, you need to get emergency medical help right away. A breathing tube may needed to be placed through your mouth or nose and into the lungs to restore breathing. You may need to have surgery called a tracheostomy that creates an opening through the neck into the windpipe. Airway compromise is always synonymous with the term Ludwig’s angina, and it is the leading cause of death ².

Antibiotics are given to fight the infection. They are most often given through a vein until symptoms go away. Antibiotics taken by mouth may be continued until tests show that the bacteria have gone away.

Dental treatment may be needed for tooth infections that cause Ludwig’s angina.

Surgery may be needed to drain fluids that are causing the swelling.

Figure 1. Ludwig angina

Footnote: A 58-year-old healthy man was evaluated for a toothache of 2 days’ duration. He was treated with oral penicillin and an opiate analgesic and advised to have the affected teeth pulled. He returned less than 24 hours later reporting severe swelling in the neck, sore throat, chills, and chest pain. On examination, the floor of his oral cavity was indurated and woody, and he had marked tenderness and adenopathy throughout his neck. He had erythema spreading from his neck down over his anterior chest wall where his chest pain was localized (Panels A and B). He did not have appreciable stridor or trismus, and he was able to swallow his own secretions. Ludwig’s angina is an infectious process involving the submental, sublingual, and submandibular spaces. It can rapidly progress to hemodynamic instability and airway obstruction; in rare cases, it spreads into the mediastinum. Compromise of the airway can progress rapidly, with lethal consequences; therefore, immediate consideration should be given to surgical débridement of the infected areas and antimicrobial therapy. In addition, options for surgical management of the airway should be available. The patient was admitted and underwent extensive surgical débridement. He recovered after a stay in the intensive care unit.

Is Ludwig angina contagious

No. Ludwig’s angina is a submandibular space or sublingual space infection that often develops after an infection of the roots of the teeth (such as tooth abscess) or a mouth injury.

Ludwig’s angina causes

The most common cause of Ludwig’s angina is dental disease in the lower molars mainly second and third which accounts for over 90% of cases ¹. Any recent infection or injury to the area may predispose the patient to develop Ludwig’s angina. Some common causes include injury or laceration to the floor of the mouth, mandible fracture, tongue injury, oral piercing, osteomyelitis, traumatic intubation, peritonsillar abscess, submandibular sialadenitis and infected thyroglossal cysts. Predisposing factors include diabetes, oral malignancy, dental caries, alcoholism, malnutrition, and immunocompromised status.

Ludwig’s angina usually starts as a cellulitis of the submandibular space ¹. The infection usually starts as a dental infection of the second or third mandibular molar teeth ¹. Other sources of infection include local spread from a peritonsillar abscess or suppurative parotitis. The infection spreads medially rather than laterally because the medial side of the periodontal bones is thin. The infection initially spreads to the sublingual space and progresses to the submandibular space. Since the infection does not spread via the lymphatic system, the infection is bilateral. The infection is usually polymicrobial involving the oral flora. The most common organisms are Staphylococcus, Streptococcus, Peptostreptococcus, Fusobacterium, Bacteroides and Actinomyces. Immunocompromised patients are at higher risk of Ludwig’s angina ¹.

Ludwig angina prevention

Visit the dentist for regular checkups.

Treat symptoms of mouth or tooth infection right away.

Ludwig’s angina differential diagnosis

Differential diagnosis includes peritonsillar abscess, retropharyngeal abscess, submandibular abscess, epiglottitis, oral carcinoma, angioedema, submandibular hematoma, and diphtheria. Although Ludwig’s angina is a clinical diagnosis, it may be difficult to differentiate from other diseases initially. Imaging may be helpful in this situation for Ludwig’s angina and also to rule out other causes of the patient’s symptoms. Typically, it does not result in abscess formation and it does not involve the lymphatic system.

Ludwig’s angina symptoms

In Ludwig angina the infected area swells quickly. This may block the airway or prevent you from swallowing saliva.

The most common presenting symptoms of Ludwig angina are fever and chills with neck swelling, neck pain, odynophagia (painful swallowing) and dysphagia (difficulty swallowing). People often describe the appearance as a “bull neck.” Less common symptoms include mouth pain, hoarse voice, drooling, tongue swelling, stiff neck and sore throat. Stridor may indicate impending airway obstruction. Patients will not have trismus unless the infection has spread into the parapharyngeal space. On physical exam, patients will have a fever with bilateral induration due to submandibular swelling and tenderness, swelling to the floor of the mouth, tenderness to the involved teeth, stiff neck, edema in the upper part of the neck, and crepitus. The patient will not typically have lymphadenopathy.

Ludwig angina symptoms include:

• Breathing difficulty
• Difficulty swallowing
• Drooling
• Unusual speech (sounds like the person has a “hot potato” in the mouth)
• Tongue swelling or protrusion of the tongue out of the mouth
• Fever
• Neck pain
• Neck swelling
• Redness of the neck

Other symptoms that may occur with Ludwig angina:

• Weakness, fatigue, excess tiredness
• Confusion or other mental changes
• Earache

Ludwig angina possible complications

Ludwig’s angina is a rapidly progressive cellulitis which can cause airway obstruction requiring immediate intervention. Close monitoring is required to prevent extension of the cellulitis to the adjacent areas. Ludwig’s angina can cause mediastinitis or necrotizing cellulitis of the neck. Ludwig’s angina can also cause aspiration pneumonia.

Ludwig angina complications may include:

• Airway blockage
• Generalized infection (sepsis)
• Septic shock

Ludwig angina diagnosis

A clinical diagnosis should be made based on presentation. Your health care provider will do an exam of your neck and head to look for redness and swelling of the upper neck, under the chin.

The swelling may reach to the floor of the mouth. Your tongue may be swollen or pushed up to top of your mouth.

You may need a CT scan. CT scan of the soft tissue neck with intravenous (IV) contrast is used to evaluate the severity of the infection and airway obstruction. CT is also useful to determine which patients will require surgical intervention for the formation of an abscess. Ultrasound may also be useful to identify the formation of an abscess. However, Ludwig’s angina usually does not result in an abscess formation. Therefore, it is often difficult to obtain cultures to determine what bacteria is causing the infection.

A sample of the fluid from the tissue may be sent to the lab to test for bacteria. Laboratory testing, although common in clinical practice, may be of little value as this is a clinical diagnosis. Blood cultures should be obtained to determine if there is the hematogenous spread of the infection.

Ludwig angina treatment

Early airway management is critical to the treatment of Ludwig’s angina as the most common cause of death is sudden asphyxiation from airway obstruction. Flexible fiberoptic nasal intubation is clinician’s favored method of intubation. The provider with the most experience should manage the airway as it will often be very challenging. Video laryngoscopy may be an option although there are no studies to date on this issue. Standard direct laryngoscope may be very challenging because of the swelling of the upper airway. It is important to manage the airway before the presence of stridor or cyanosis as these are late findings. If the patient is not able to be intubated, the next step would be an emergency tracheotomy. Cricothyrotomy is very challenging because of the edema in the neck which can obscure the anatomy.

Early broad-spectrum IV antibiotics have been shown to be helpful. For patients who are immunocompetent, a reasonable first choice would be ampicillin-sulbactam or clindamycin. Antibiotics should cover gram-positive bacteria, gram-negative bacteria, and anaerobes. For patients who are immunocompromised, the coverage should be broadened to cover for pseudomonas. Some options include cefepime, meropenem, or piperacillin-tazobactam. MRSA coverage should be considered for patients who are immunocompromised, increased risk of methicillin-resistant Staphylococcus aureus (MRSA) or prior MRSA infection. IV steroids are controversial. Several case reports have shown the decrease in the need for airway management with the use of steroids. However, more studies are needed before it becomes standard of care. Duration of the antibiotics are usually two to three weeks. White blood cell count and fever needs to be monitored closely.

Ludwig angina surgery

Dental extraction is recommended if the source of the infection is odontogenic. For patients who do not respond to initial antibiotics or develop a fluid collection on imaging, needle aspiration or surgical incision and drainage may be performed. Surgery is usually reserved for patients who fail medical therapy as early surgical decompression has not been shown to improve outcomes.

Ludwig angina prognosis

Due to the life-threatening complication of airway obstruction from Ludwig’s angina, mortality exceeded 50% prior to the development of antibiotics. With antibiotic therapy, along with improved imaging modalities and surgical techniques, mortality is approximately 8%.

1. An J, Singhal M. Ludwig Angina. [Updated 2018 Dec 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482354[↩][↩][↩][↩][↩][↩][↩]
2. [↩]
3. Ludwig’s Angina. N Engl J Med 2008; 359:1501 DOI: 10.1056/NEJMicm065036 https://www.nejm.org/doi/full/10.1056/NEJMicm065036[↩]