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Varicocele: causes, symptoms, diagnosis and treatment

  1. Gastroepato
  2. Nefrologia
  3. Varicocele: causes, symptoms, diagnosis and treatment
  4. Male infertility

notes by  dr Claudio Italiano

Varicocele

Is defined as a primitive or secondary varicose dilatation of the intrafunicular spermatic plexus. The testes receive blood from the testicular artery; the blood is then transported via a series of small veins located in the scrotum, precisely the veins of the pampiniform plexus. From here the blood flows back into the internal spermatic vein (testicular vein). The venous circulation of the testis is responsible for a lowering of the temperature of the same, which happens in physiological conditions, that is when the circulatory function is conserved. Vice versa in the pathological condition of varicocele, so to speak, the testicle overheats and loses its function as a male seed producer. Then the specific interest of this affection, in itself low morbidity, is related to the relationships between it and male infertility or subfertility. It usually occurs between the ages of 15 and 25, exceptionally earlier, very rarely in old age. It has a high incidence (around 15% of young people visited at the lever); in 85% of cases it is localized to left, 11% is bilateral and only 4% to right.


We distinguish:

a) the very frequent primitive varicocele is linked to a venous blood reflux in the gonadal vein (species on the left, where it enters perpendicularly into the renal vein) due to a congenital valvular insufficiency or to other anomalies that affect the gonadal vein primitively.

b) the secondary varicocele, much rarer, is instead supported by gonadal vein obstruction for neoplasia of the kidney with diffusion in the left renal vein or for retroperitoneal neoplasms. The thermal gradient (+ 2 °, + 3 ° C) that the reflux and the venous stasis determine at the scrotal level is certainly responsible for damage to the germline and interstitial alterations. However, it has been hypothesized that reflux of catecholamines from the left adrenal vein may also negatively affect testicular function. The bilaterality of testicular damage is explained by the presence of anastomosis between the venous systems of the two hemiscrotes. From the macroscopic point of view we observe the dilatation, the tortuosity, the lengthening of the veins of the spermatic cord.

The scrotum shows a state of atony and flaccidity and inside it is appreciated the presence of a decreased testicle of volume and sometimes completely atrophic. However, the histological changes that the glandular tissue undergoes and which affect both the testicles are more important. The most characteristic finding, even if not pathognomonic, at the level of the seminiferous epithelium is the maturational arrest that in the milder forms affects only the most mature cell series (spermatocytes of second order, spermatids, spermatozoa), while in the more severe forms it affects also the less differentiated cell lines (spermatocytes of the first order, spermatogoni). The interstitium is also affected, showing varying degrees of fibrosis of the vessel walls. Leydig cells may present aspects of immaturity. The damage to the seminal pathway translates, on the practical level, into an alteration of the sperm content basically consisting of oligoastenospermia, in the presence of immature forms, in a notable decrease in the motility of the spermatozoa and sometimes in a azoospermia.

Clinical picture and diagnosis of varicocele

In a large number of cases the varicocele is completely asymptomatic; it is not uncommon, however, that the affected subject complains a sense of scrotal heaviness, fleeting testicular pains, a sensation of warmth, particularly after prolonged periods of erect posture or physical stresses of various kinds. The diagnosis of confirmed varicocele does not present particular difficulties and the clinical examination of the patient is sufficient to ascertain its presence. The objective examination in a clinostatic position allows to appreciate the partially emptied pampiniform plexus; subsequently, in orthostatism, the gradual and often rapid filling of the venous plexus appears turgid in the context of a flaccid scrotum. In doubtful cases it is advisable to have a Valsalva maneuver performed which makes the filling of the plexus more evident. Scrotal ultrasound is the fastest, cheapest and bloodless way to diagnose varicoceles. A seminal fluid examination and an Eco-Doppler are required. The Eco-Doppler is a non-invasive examination that involves ultrasound very similar to the ultrasound. The Eco-Doppler is usually performed with the patient standing in such a way that the blood-filled veins are more easily visible. The eco-doppler survey is able to detect the inversion of blood flow in the gonadal vein, even in the milder forms of varicocele. The identification of the ectasic pampiniform flexion is easy but the role of the ultrasound is precious above all for the objective evaluation of the testicular diameters. A hypotrophy of the testis, in fact, is a negative prognostic index for the damage induced to the seminal line. It is now well established that testicular volume is a primary indicator for the prognostic clinical evaluation of the recovery of effective spermatogenesis, since the tubular portion and the germ elements contribute to the volume by 98%. Intraoperative phlebography is performed both proximal and distal to the section of the gonadal vein. From precise information on the venous system and should always be performed during the surgery.

Treatment

Varicocele treatment might not be necessary. Many men with varicoceles are able to father a child without any treatment. However, if your varicocele causes pain, testicular atrophy or infertility or if you are considering assisted reproductive techniques, you might want to undergo varicocele repair.

The purpose of surgery is to seal off the affected vein to redirect the blood flow into normal veins.
The first option is percutaneous sclerotembolization through a catheter which is performed by an Interventional Radiologist. The second option is the surgery performed by the surgeon or urologist, with the aim of blocking venous reflux and, therefore, facilitating the discharge of the pampiniform plexus.
The techniques used are:
a) retroperitoneal ligation
b) inguinal ligation
c) sub-colonial ligation
If the varicocele does not cause subjective disorders and is not a cause of infertility, no type of therapy seems advisable (sometimes it is sufficient that the patient should wear the "briefs" instead of the "boxers".

cfr  index_nefrologia