MEN'S HEALTH MATTERS:A varicocele is a group of dilated veins around the spermatic cord
Q I am 35 years old and have been married for three years. I have had a swelling around my left testicle for some time and as my wife and I are having difficulty conceiving a baby I attended my doctor recently for his advice. He has diagnosed a varicocele. What exactly is this and do I need to do anything about it?
A A varicocele is a collection of dilated veins around the spermatic cord and often feels like a lump in the scrotum. They are sometimes visible and have often been described to feel like a bag of worms.
They usually begin to develop during puberty, are almost exclusively left sided and affect 15-20 per cent of the normal male population. They have been shown to be associated with decreased testicular size, but not with abnormal motility or morphology of the sperm.
It is widely accepted that varicoceles are associated with male sub-fertility. The mechanisms as to why this should be so have not been satisfactorily explained, but a number of hypotheses have been advanced.
The temperature of the testicles is one degree lower than body temperature due to the fact that they are in the scrotum. This lower temperature is necessary for spermatogenesis (manufacture of sperm), but the presence of a varicocele may increase this temperature thus impairing spermatogenesis.
It is felt that spermatogenesis might also be impaired by inadequate blood drainage or raised testicular pressure.
However, the conventional notion that varicoceles are associated with sub-fertility is open to question as many men with normal fertility have varicoceles. Researchers in the United States have recently shown that there is no real evidence to support the practice of varicoceles repair as an effective treatment for male sub-fertility.
Many men with varicoceles have unimpaired fertility, but there is a certain logic to repairing them in those men who are sub-fertile. Many varicoceles can be obliterated using radiological techniques and do not require surgery.
Q I am 29 and attended my doctor because of swelling of my face, which involved my lips, and also around my eyes. This problem has been present on an intermittent basis for several years. The swelling can also involve other sites, including my hands and arms. I occasionally develop an itchy, red rash all over my body. I was told that I have an allergy, but I cannot identify the cause.
A This medical problem is quite common and it may be that an allergy is responsible and if that is the case, the cause of the allergy is usually fairly obvious.
Chief suspects as a cause of allergy are foods or drugs. However, in most cases there is a clear-cut relationship between the intake of the food or drug and the development of the swelling or rash.
Usually, the reaction to these substances takes place within an hour of intake and often much quicker – within five or 10 minutes. In the case of food allergy, a patient will often notice symptoms such as tingling in the mouth or lips within minutes of food ingestion. If, however, there is no history of foods being associated, then food allergy is very unlikely.
Likewise, if you are not taking drugs, this eliminates these as a cause. Certain drugs are particularly associated with rash and swelling; these include antibiotics, anti-inflammatory and some drugs used to treat blood pressure. It is important when discussing a patient’s symptoms, to specifically inquire about these products – as a patient may not volunteer their use.
If this is a long-standing complaint as you suggest and you have not been able to identify any trigger causing it, it is unlikely that a single specific cause will be found. The medical term for his skin rash is “urticaria”– which has a typical nettle sting appearance.
The term for the skin swelling is “angioedema” and is due to leaking of fluid from blood vessels beneath the skin.
Commonly, a combination of events are involved in causing this condition. These include genetic predisposition, the climate, hormonal levels (especially in women) and viral infections.
When a patient has such a medical condition, it can be very disabling – both from a work and social point of view. It is important to get sound medical advice on how to deal with the problem. This advice will include careful consideration about possible triggers of the condition and eliminating these if they are present.
Strong reassurance is also very important, as patients may begin to despair about their situation and also worry about how it might become life threatening. This is particularly the case if they have had swelling of the tongue or developed a sensation of choking.
Some patients may have already started to eliminate dietary products and they can be advised to stop this, unless there is good evidence that foods are involved.
Many patients, with a history similar to your own, will respond well to the use of anti-histamine drugs. These can be used safely on a long-term basis. Newer, long-acting anti-histamines are now available and these are often very effective in controlling such symptoms. Occasionally, a combination of anti-histamines is employed.
If the above approach is not successful in controlling your symptoms, then referral to a specialist with training in immunology or allergic diseases is warranted. Allergy diagnosis and treatment relies on careful assessment of a patient’s history, physical examination and appropriate scientific tests (blood testing and skin testing).
These can be performed only by trained medical practitioners as the use of non-scientific methods to diagnose allergic conditions can be misleading and should be discouraged.
This weekly column is edited by Thomas Lynch, consultant urological surgeon, St James’s Hospital, Dublin, with contributions from Prof Conleth Feighery, consultant immunologist, and Dr Mohamed Abuzakouk, lecturer in immunology/allergy
