Effects of varicocelectomy on sleep quality: Varicocele may affect sleep quality

Fatih Atac; Unal Oztekin; Mehmet Caniklioglu; Sercan Sari; Adem Tokpinar; Gokhan Sonmez

doi:10.4103/UROS.UROS_164_20

ORIGINAL ARTICLE

Year : 2021 | Volume : 32 | Issue : 4 | Page : 182-185

Effects of varicocelectomy on sleep quality: Varicocele may affect sleep quality

Fatih Atac¹, Unal Oztekin², Mehmet Caniklioglu², Sercan Sari², Adem Tokpinar³, Gokhan Sonmez⁴
¹ Department of Urology, Batman Zilan Private Hospital, Batman, Turkey
² Department of Urology, Yozgat Bozok University, Yozgat, Turkey
³ Department of Anatomy, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
⁴ Department of Urology, Faculty of Medicine, Erciyes University, Kayseri, Turkey

Date of Submission	30-Nov-2020
Date of Decision	07-Jun-2021
Date of Acceptance	05-Jul-2021
Date of Web Publication	14-Dec-2021

Correspondence Address:
Dr. Unal Oztekin
Yozgat Bozok University, Faculty of Medicine, 7^th km, Ataturk Road, Yozgat
Turkey

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/UROS.UROS_164_20

Abstract

Purpose: The relationship between sleep quality and testosterone levels has been known. However, there are no data whether sleep quality and varicocelectomy have a relationship. Therefore, we aimed to investigate the effect of varicocelectomy on sleep quality and testosterone levels. Materials and Methods: A total of 39 patients with painful left grade 3 varicocele were included in the study. Visual analog scale, serum testosterone levels, Pittsburgh sleep quality index (PSQI) including subparameters of sleep were questioned and recorded preoperatively and postoperatively. Results: There was a significant difference between the preoperative and postoperative parameters of both PSQI and subparameters of sleep (P < 0.05). After the operation, 36 (92.3%) patients had remarkable pain relief. Testosterone levels of 32 (82%) patients increased. Conclusion: We concluded that a remarkable improvement in sleep quality was provided after varicocelectomy. Furthermore, evaluation of varicocele may be useful in male patients with unexplained sleep disorders.

Keywords: Pain, Pittsburgh sleep quality index, sleep quality, varicocele, varicocelectomy

How to cite this article:
Atac F, Oztekin U, Caniklioglu M, Sari S, Tokpinar A, Sonmez G. Effects of varicocelectomy on sleep quality: Varicocele may affect sleep quality. Urol Sci 2021;32:182-5

How to cite this URL:
Atac F, Oztekin U, Caniklioglu M, Sari S, Tokpinar A, Sonmez G. Effects of varicocelectomy on sleep quality: Varicocele may affect sleep quality. Urol Sci [serial online] 2021 [cited 2023 May 28];32:182-5. Available from: https://www.e-urol-sci.com/text.asp?2021/32/4/182/332406

Introduction

A varicocele is an abnormal dilatation of the internal and external spermatic veins in the pampiniform plexus of the spermatic cord with a prevalence rate of 15%. Although the majority of the cases are asymptomatic, the most common symptoms are chronic pain and infertility.^[1],[2] The pain associated with varicocele is localized, especially in the scrotum and inguinal region and usually worsens with physical effort.^[3] Although the nerve fibers surrounding the dilated venous complex are known to be attributed to this pain, the pathophysiology between varicocele and the pain associated with it has not yet been elucidated.^[4]

Varicoceles are the most frequent curable cause of infertility.^[5] Spermatogenesis and Leydig cell function are affected because of the increased levels of testicular venous pressure, testicular temperature, toxic metabolic rates and oxidative stress, and also hormonal imbalances.^[6]

Varicocelectomy is an effective treatment for varicocele. Various techniques have been described for venous ligation to prevent retrograde flow in the spermatic veins, including the retroperitoneal (Palomo), inguinal (Ivanissevich), subinguinal, and scrotal approaches.^[7],[8],[9] Microsurgical approaches have been recommended since they result in less recurrence rates and less complications, such as hydrocele. These techniques resulted in similar pain relief rates in painful varicocele. Therefore, varicocelectomy is considered a standard treatment for painful varicocele.^[10]

Given the recent scientific data, sleep plays a critical role in human health. However, sleep deprivation in modern societies has become endemic. In 2015, the American Academy of Sleep Medicine and the Sleep Research Society built a consensus that 7–9 h of sleep is enough to reach optimal health status for adults.^[11] Short sleep durations have been associated with numerous metabolic and endocrinological problems. Moreover, a recent review has revealed that inadequate sleep is a risk factor for obesity and type 2 diabetes.^[12] It is known that sleep disorders are related to painful processes in any system of the body.^[13]

Therefore, this study aims to investigate the effect of varicocelectomy on sleep quality and testosterone levels both in the preoperative and the postoperative periods in patients with painful Grade 3 varicocele.

Methods

Ethical approval was obtained from the local ethics committee (2017-KAEK-189_2018.05.30_07). The study was conducted between May 2018 and November 2018 in accordance with the Helsinki Declaration. A total of 39 patients who complained of scrotal pain for at least 3 months because of left Grade 3 varicocele were included in the study. The mean age of the patients was 26 years. Fifteen of the patients were single, and 24 of them were married. Informed consent was obtained from all of the patients. Age and body mass index (BMI) were recorded as demographic data for each patient. Since the probability of sleep quality might be impaired, the patients with chronic obstructive pulmonary disease, heart failure, psychiatric cases, and obstructive sleep apnea syndrome were not included. Moreover, the exclusion criteria also included the possible causes of scrotal pain, which are indirect inguinal hernia, ureteral calculi, hydrocele, spermatocele, testicular mass, and history of vasectomy.

The visual analog scale (VAS) scores, serum testosterone levels, and Pittsburgh sleep quality index (PSQI) scores including the subparameters of sleep (sleep duration, sleep disturbances, sleep latency, daytime functionality loss, habitual sleep efficiency, subjective sleep quality, and the use of sleeping medication) were measured and recorded before the surgery.^[14],[15] The same questionnaires were administered on the 3^rd month of the operation.

Surgery was performed by two experienced surgeons using the microsurgery technique via subinguinal incision. Analgesic drugs were administered to each patient for pain relief if it is necessary in the 1^st week after the operation. The patients were discharged on the first postoperative day.

Statistical analysis

IBM SPSS Statistics for Windows, v25.0 (IBM Corp. Released 2017. Armonk, NY, USA) was used for statistical analysis. The Shapiro–Wilk normality test was used to determine the normal distribution of the data. The numerical data were analyzed using the paired sampled t-test. A statistical value of P < 0.05 was considered statistically significant.

Results

The mean age of the patients was 26.7 ± 5.50 years. Fifteen patients were married, and 24 of them were single. Moreover, the mean BMI of the patients was 24.1 ± 2.91 kg/m².

[Table 1] shows the evaluation of sleep quality and the subparameters of sleep among the patients before and after surgery. A statistically significant difference was observed between the preoperative and postoperative parameters of PSQI and the subparameters of sleep (P < 0.05). Moreover, these parameters were significantly increased after the operation. The sleep quality of 34 (87.2%) patients improved. However, no significant difference was observed in four (10.25%) patients, and only one patient had an impaired sleep quality [Table 1].

Table 1: Pittsburgh sleep quality index, subparameters of sleep, and visual analog scale scores of preoperative and postoperative periods

Click here to view

[Table 2] shows the patients' preoperative and postoperative VAS scores and testosterone levels. After the operation, 36 (92.3%) patients had slight pain, whereas only three (7.7%) patients did not feel any difference regarding pain relief. Thirty-two of the 36 patients who experienced pain relief after the operation showed improvement in their sleep quality scores.

Table 2: Comparison of preoperative and postoperative evaluation of visual analog scale scores and testosterone levels

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As another parameter, the testosterone levels of 32 (82%) patients increased, whereas those of the other patients reduced after the operation [Table 2].

Discussion

Varicoceles may affect spermatogenesis adversely and are accepted as one of the causes of infertility. Infertility is the most common indication for varicocelectomy.^[15] However, scrotal pain may be another indication for surgery. The incidence of pain in men diagnosed with varicocele is estimated to be up to 10%, and varicocele is the cause of pain in 2%–14% of men with chronic scrotal pain. Chronic scrotal pain decreases performance in daily activities.^[3] The pathophysiology between varicocele and the pain associated with it has not been clarified yet. Moreover, the compression of nearby nerve fibers caused by dilated venous complex, increased scrotal temperature, ischemia, and oxidative stress secondary to venous stasis has also been determined to be attributed to the pain associated with varicocele.^[15],[16]

Surgery may be a solution for scrotal pain. In the literature, it has been reported that scrotal pain is partially or completely relieved in 83%–100% of patients after surgery.^[7],[8] In the present study, the pain completely stopped in 36 (92%) patients, whereas the pain scores of three (8%) patients did not change.

Sleep disorders may manifest in painful situations.^[13] As mentioned above, 10% of varicocele cases may suffer from scrotal pain.^[3] Chronic scrotal pain in patients with varicocele may cause sleep disorders in this population. In concordance with this hypothesis, the present study has shown that the patients with symptomatic varicocele did not have a good sleep quality. Moreover, these patients benefit from varicocelectomy regarding their sleep quality. This finding was similar to that of the literature. The benefits of chronic pain relief on sleep quality have been emphasized.^{[17],[18],[19]}

Sleep quality is one of the parameters of quality of life. Reduced sleep quality due to pain has a significant impact on the patient's general well-being and quality of life.^[20] Sleep quality is assessed by evaluating the PSQI scores and subparameters of sleep together.^[15] In the present study, 34 patients (87.2%) showed a significant improvement in sleep quality. Among them, the sleep quality of 32 patients was correlated with pain relief in the study population. The most significant improvement was observed in sleep latency (preoperative mean 1.28 ± 0.82, postoperative mean 0.67 ± 0.7; P < 0.05). Thus, it can be concluded that the clinical or subclinical pain secondary to varicocele exerts a powerful effect on sleep duration. However, obviously, more controlled studies are needed to confirm this relationship.

Although the daily changes in testosterone were first determined in 1965, the specific relationship between sleep and testosterone was first investigated by Evans et al. in 1971.^[21] Since then, many studies have corroborated the connection between sleep and testosterone. In the last decade, several sleep deprivation studies have shown that short periods of sleep or periods of prolonged awakening cause a slight reduction in testosterone levels.^[22] When Leproult and Van Cauter limited the sleep duration of healthy men to 5 h for a week, their plasma testosterone levels were determined to reduce by 10%–15% in their study population.^[23] In another study, Schmid et al. performed sleep restriction in the second half of the night and showed that it was the actual period responsible for the decline in testosterone levels.^[24] Furthermore, varicocelectomy is determined to produce positive effects on testosterone levels. Interestingly enough, good-quality sleep has similar beneficial effects on testosterone levels.^[25] In other similar studies, these findings will lead to difficulties in determining which of them is responsible for the increase in testosterone levels unless the relationship between these parameters is clarified. Moreover, the relationship between sleep and testosterone levels has not yet been elucidated. Although studies have concluded that the increase in testosterone levels could be associated with increased testicular blood flow, increased Leydig cell sensitivity for luteinizing hormone, and decreased sex hormone-binding globulin concentrations via postural changes,^[26] more studies are needed to prove this.

It has been shown that shortened sleep duration, advanced age, and increased BMI are associated with lower testosterone levels.^[27] In the present study, the median age was 26 years, and 18 patients were under 25. Moreover, the mean BMI was 24.1 ± 2.91 kg/m². In the present study, it was concluded that the sleep quality and testosterone levels of patients with painful varicoceles were significantly affected even in this young and healthy population.

In the literature, studies have suggested that testosterone levels increase after varicocelectomy. The presence of varicocele may inhibit Leydig cell function and reduce testosterone levels.^[28] Najari et al. reported a mean follow-up of 34 patients during 20.6 months after varicocelectomy with an increase in serum testosterone levels (136.0 ± 201.3 ng/dL). They claimed that varicocelectomy has the potential to improve sexual function by influencing serum testosterone levels.^[25] Similarly, Hsiao et al. have found increased testosterone levels (109.1 ± 12.8 ng/dL) in 78 patients during a 7-month follow-up after varicocelectomy, and they emphasized that varicocelectomy was associated with a significant increase in serum testosterone levels independent of the varicocele grade.^[29] By contrast, some studies have reported that varicocelectomy does not cause a significant increase in testosterone levels.^[30] In the present study, we evaluated the 3-month follow-up results of our patients and found that the average testosterone increase value was 51.48 ± 55.42 ng/dL. However, as a limitation of this study, we cannot distinguish the proportions of the effects of varicocelectomy and sleep quality on testosterone levels separately.

Given these findings, several issues have not been addressed yet. We cannot determine whether sleep quality or varicocelectomy is mostly responsible for the increase in testosterone levels. Moreover, we do not know whether pain relief or the increase in testosterone levels enhances sleep quality the most. Thus, further randomized prospective studies are needed. As another limitation of this study, the findings are based on the results of the questionnaires instead of quantitative measurements in a sleep laboratory. Prospective studies designed in a sleep laboratory may address these limitations in future.

Conclusion

The relationship between sleep quality and testosterone levels has been determined, as well as the relationship between varicocelectomy and testosterone levels. However, no data have been produced to prove the relationship between varicocelectomy and sleep quality. Therefore, the present study aims to investigate the effect of varicocelectomy on sleep quality and testosterone levels. To our knowledge, this is the first study to investigate the effect of varicocelectomy on sleep quality. On the basis of the findings of the present study, we concluded that a remarkable improvement in sleep quality was observed after varicocelectomy. It can be suggested that this benefit is related to the significant scrotal pain relief after varicocelectomy. However, this can only be confirmed in large randomized prospective studies. Even so, on the basis of the results of the present study, we suggest that the evaluation of varicocele may be useful in treating male patients with unexplained sleep disorders.

It is known that good-quality sleep improves the quality of life and has a positive effect on testosterone levels. Although we do not know whether sleep quality or varicocelectomy is responsible for this, in concordance with the literature, a significant increase in serum testosterone levels after varicocelectomy was observed in the present study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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