Varicocele

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Varicocele
Classification and external resources

Cross section showing the pampiniform plexus
ICD-10 I86.1
ICD-9 456.4
DiseasesDB 13731
MedlinePlus 001284
MeSH D014646


Varicocele in ultrasound (left: testicle)
Varicocele /vrksil/ is an abnormal enlargement
of the pampiniform venous plexus in the scrotum. This
plexus of veins drains the testicles. The
testicular blood vessels originate in the abdomen and
course down through the inguinal canal as part of
the spermatic cord on their way to the testis. Upward
flow of blood in the veins is ensured by small one-way
valves that prevent backflow. Defective valves, or
compression of the vein by a nearby structure, can
cause dilatation of the testicular veins near the testis,
leading to the formation of a varicocele.


Significant left-sided varicocele.
Contents
[hide]
1 Signs and symptoms
2 Cause
3 Pathophysiology
4 Diagnosis
5 To treat or not?
6 Possible treatment
7 Prognosis
8 References
9 External links
Signs and symptoms[edit]
Symptoms of a varicocele may include:
Dragging-like or aching pain within scrotum.
Feeling of heaviness in the testicle(s)
Atrophy (shrinking) of the testicle(s)
Alteration of testosterone levels.
[improper
synthesis?][1][2][3][4][5][6][7][8][9][10]

Visible or palpable (able to be felt) enlarged
vein
[11]

Cause[edit]
The idiopathic varicocele occurs when the valves
within the veins along the spermatic cord do not work
properly. This is essentially the same process
as varicose veins, which are common in the legs. This
results in backflow of blood into the pampiniform
plexus and causes increased pressures, which on
rare occasion can lead to permanent damage to the
testicular tissue due to disruption of normal supply of
oxygenated blood via the testicular artery.
Varicoceles develop slowly and may not have any
symptoms. They are most frequently diagnosed when
a patient is 1530 years of age, and rarely develop
after the age of 40. They occur in 15-20% of all males.
A majority of idiopathic varicoceles occur on the left
side,
[12]
apparently because the left testicular
vein connects to the renal vein (and does so at a 90-
degree angle), while the right testicular vein drains at
less than 90-degrees directly into the significantly
larger inferior vena cava. Isolated right sided
varicoceles are rare.
[citation needed]

A secondary varicocele is due to compression of the
venous drainage of the testicle. A pelvic or abdominal
malignancy is a definite concern when a right-sided
varicocele is newly diagnosed in a patient older than
40 years of age. One non-malignant cause of a
secondary varicocele is the so-called "Nutcracker
syndrome", a condition in which the superior
mesenteric artery compresses the left renal vein,
causing increased pressures there to be transmitted
retrograde into the left pampiniform plexus.
[13]
The
most common cause is renal cell carcinoma (a.k.a.
hypernephroma) followed by retroperitoneal fibrosis or
adhesions.
Pathophysiology[edit]
The term varicocele specifically refers to dilatation
and tortuosity of the pampiniform plexus, which is the
network of veins that drain the testicle. This plexus
travels along the posterior portion of the testicle with
the epididymis and vas deferens, and then into the
spermatic cord. This network of veins coalesces into
the gonadal, or testicular, vein. The right gonadal vein
drains into the inferior vena cava, while the left
gonadal vein drains into the left renal vein at right
angle to the renal vein, which then drains into the
inferior vena cava. One of the main functions of the
plexus is to lower the temperature of the testicles;
vericocele causes this function to be lost, hence the
most common complication of untreated vericocele is
higher temperature of the testes, resulting in testicular
atrophy causing infertility.
[citation needed]

The small vessels of the pampiniform plexus normally
range from 0.51.5 mm in diameter. Dilation of these
vessels greater than 2 mm is called a varicocele.
[citation
needed]

Recent studies have shown that the detrimental effect
of varicocele on sperm production is progressive and
due to reduction in supply of oxygenated blood and
nutrient material to the sperm production sites, which
persistently reduces the quality and the quantity of the
sperms, leading to reduction in their fertility capacity
with time.
[citation needed]

Diagnosis[edit]
Upon palpation of the scrotum, a non-tender, twisted
mass along the spermatic cord is felt. Palpating a
varicocele can be likened to feeling a bag of
worms.
[14]
When one is lying down, gravity may allow
the drainage of the pampiniform plexus and thus
make the mass not obvious.
[14]
This is especially true
in primary varicocele, and absence may be a sign for
clinical concern.
[14]
The testicle on the side of the
varicocele may or may not be smaller compared to
the other side.
Varicocele can be reliably diagnosed
with ultrasound,
[15][16]
which will show dilation of the
vessels of the pampiniform plexus to greater than
2 mm. The patient being studied should undergo a
provocative maneuver, such as Valsalva's
maneuver (attempting expiration against a closed
airway) or standing up during the exam, both of which
are designed to increase intra-abdominal venous
pressure and increase the dilatation of the veins.
Doppler ultrasound is a technique of measuring the
speed at which blood is flowing in a vessel. An
ultrasound machine that has a Doppler mode can see
blood reverse direction in a varicocele with a Valsalva,
increasing the sensitivity of the examination.
Recent studies have shown that varicocele is a
bilateral disease
[17]
and the diagnosis of the right side
is missed by physical examination and even by
ultrasonography. The examination should be
performed by ultrasonography color flow doppler
performed by highly experienced sonographer or
radiologist that will diagnose varicocele by
demonstrating back-flow in the right and in the left
spermatic veins.
[18]

To treat or not?[edit]
A Cochrane review in 2013 grossly estimated that
when performing surgical or radiological treatment of
varicocele in subfertile men with a clinically manifest
varicocele and poor semen quality, one additional
pregnancy will be obtained for approximately every 7
men treated.
[clarification needed][19]

A meta-analysis in 2011 of the available literature
concluded that varicocelectomy improves sperm
parameters (count and total and progressive motility),
reduces sperm DNA damage and seminal oxidative
stress, and improves sperm ultramorphology. Studies
also indicate that a microsurgical approach to a
varicocele repair results in less recurrence and fewer
complications than other techniques.
[20]

Surgical treatment is generally reserved for those with
symptomatic varicocele, a discrepancy in testicular
size or marked semen abnormalities in patients with a
palpable varicocele at rest. There are also non-
invasive natural treatment options that may relieve
symptoms.
[21]

Possible treatment[edit]


Sewn up wound after varicocele surgery
Varicocelectomy, the surgical correction of a
varicocele, is performed on
an outpatient basis.
[22]
The three most common
approaches
areinguinal (groin), retroperitoneal (abdominal), and
infrainguinal/subinguinal (below the groin). Various
other techniques may be used. Ice packs should be
kept to the area for the first 2 days after surgery to
reduce swelling. The patient may be advised to wear
a scrotal support for some time after surgery.
Possible complications of this procedure
include hematoma (bleeding into
tissues), hydrocele (accumulation of fluid around the
affected testicle), infection, or injury to the scrotal
tissue or structures. In addition, injury to the artery
that supplies the testicle may occur.
In the Gat-Goren nonsurgical method for treating
varicoceles, performed under local anesthesia,
a catheter is inserted through a vein in the upper thigh.
Fluid injected through the catheter selectively closes
off the malfunctioning veins, thus enabling the
testicular tissues to recover and begin to produce
normal sperm in normal amounts. The procedure lasts
one to two hours and causes almost no discomfort.
The patient can return to his regular routine within 24
hours.
[23]



Picture taken 36 hours after embolization treating a varicocele.
It shows the place where the wire was passed through.
An alternative to surgery is embolization,
[24]
a
minimally invasive treatment for varicocele that is
performed by an interventional radiologist. This
involves passing a small wire through a peripheral
vein and into the abdominal veins that drain the testes.
Through a small flexiblecatheter, the doctor can
obstruct the veins so that the increased pressures
from the abdomen are no longer transmitted to the
testicles. The testicles then drain through smaller
collateral veins. The recovery period is significantly
less than with surgery and the risk of complications is
minimized with overall effectiveness similar to surgery,
yet with fewer recurrence rates. However, radiation
exposure to the testicles can often not be avoided
with this technique.
Embolization is an effective treatment for post-surgical
varicoceles. These are varicoceles that reappear after
they have been surgically repaired. The main theory is
the presence of redundant gonadal veins that provide
collateralization cause the reappearance of the
varicoceles. The use of NBCA glues during the
embolization is as effective at embolizing these
collaterals as coils.
[25]

Medical treatment with L-carnitine has some
beneficial effect on sperm parameters, but is not as
effective as surgery.
[26]
Micronised purified flavonoid
fractions (MPFF)(Daflon) have a beneficial effect on
reducing varicocele pain and reducing reflux time of
left spermatic vein during the Valsalva maneuver.
[27]

Natural treatment methods typically involve improving
blood circulation in the lower torso, e.g. by alleviating
constipation, reducing inflammatory effects, and
lowering blood viscosity
[28]
These methods could
involve dietary supplementation, various exercises
like swimming and cooling of the scrotum
[21][29]

Prognosis[edit]
Varicocele can be harmless, but in some cases it can
cause infertility and pain. Although there are studies
showing improvement in sperm quality in
57%,
[30]
there are also studies showing that the
regular surgery has no significant effect on infertility.
Thus the surgery may not improve fertility and the
patient will need to undergo a non-invasive
treatment.
[31][32]