Varicocele

Varicocele

Cross section showing the pampiniform venus plexus
Classification and external resources
Pronunciation /ˈværᵻkoʊˌsiːl, -kə-/[1][2]
Specialty Urology
ICD-10 I86.1
ICD-9-CM 456.4
DiseasesDB 13731
MedlinePlus 001284
eMedicine radio/739
Patient UK Varicocele
MeSH D014646

A varicocele 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. Varicocele is known as one of the main causes for male infertility and can be treated by a surgery or non-surgical treatments.

Signs and symptoms

Significant left-sided varicocele

Symptoms of a varicocele may include:

Cause

The idiopathic varicocele occurs when the valves within the veins along the spermatic cord do not work properly. This results in some backflow of blood into the pampiniform venous plexus. Venous backflow leads increases vein diameter because of excessive pressure, and testosterone pooling. Pooled blood is toxic and may cause damage to the testicles and veins. Varicoceles develop slowly and may not have any symptoms. They are most frequently diagnosed when a patient is 13–30 years of age. They occur in 15-20% of all males.

A majority of idiopathic varicoceles occur on the left side,[15] because the left testicular vein travels superiorly and connects to the left renal vein (at a 90-degree angle), while the right testicular vein drains directly into the inferior vena cava. Isolated right sided varicoceles are rare.

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 unilateral 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.[16] The most common cause is renal cell carcinoma (a.k.a. hypernephroma) followed by retroperitoneal fibrosis or adhesions.

Lifestyle

Lifestyle factors such as activity type, diet,[17] bowel health,[18] testicular temperature,[19] smoking,[20] and alcohol moderation[17] can effect both the occurrence rate and varicocele symptoms severity.[21]

Pathophysiology

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; varicocele causes this function to be lost, hence the most common complication of untreated varicocele is higher temperature of the testes, resulting in testicular atrophy causing infertility.[22]

The small vessels of the pampiniform plexus normally range from 0.5–1.5 mm in diameter. Dilation of these vessels greater than 2 mm is called a varicocele.[23]

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.

Blood from the testes that cannot drain via the pampiniform plexus may route through the prostate in a process known as communicating vessels.[14] The increased flow of blood to the prostate can lead to congestion and enlargement of the gland (BPH) both through physical mechanisms and as a result of "accelerated prostate cell proliferation [growth] resulting from the extremely high concentration of free testosterone reaching directly from the testes to the prostate".[14]

Diagnosis

Varicocele in ultrasound (left: testicle)
Varicocele

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.[24] When one is lying down, gravity may allow the drainage of the pampiniform plexus and thus make the mass not obvious.[24] This is especially true in primary varicocele, and absence may be a sign for clinical concern.[24] 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,[25][26] 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.

Treatment

MicroTSE

Couples who are infertile secondary to nonobstructive azoospermia and concurrent varicocele, are most likely to benefit from proceeding directly to microTESE and deferring varicocele repair.[27]

Surgery

Sewn up wound after varicocele surgery

Varicocele surgery may improve fertility in those with obvious findings and abnormal sperm.[28]

The surgery is performed on an outpatient basis.[29] The three most common approaches are inguinal (groin using percutaneous embolization), retroperitoneal (abdominal using laparoscopic surgery), 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.

Embolization

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,[30] 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 flexible catheter, 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.

Fertility

A 2012 Cochrane review found tentative but unclear evidence of improved fertility among males treated for varicocele.[31] The benefit may be as large as one per seven men treated.[32]

Alternative medicine

Eastern medical strategies like Yoga, tai chi, and qi gong may have positive benefits for varicocele.[17][33]

Prognosis

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%,[34] 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 nonsurgical treatment.[35][36]

References

  1. ↑ "Varicocele". Merriam-Webster Dictionary. Retrieved 2016-01-21.
  2. ↑ "Varicocele". Oxford Dictionaries. Oxford University Press. Retrieved 2016-01-21.
  3. ↑ Urologychannel: Varicoele, retrieved October 21, 2006
  4. ↑ Chen, Shiou-Sheng; Chen, Li-Kuei (2012). "Risk Factors for Progressive Deterioration of Semen Quality in Patients with Varicocele". Urology 79 (1): 128–32. doi:10.1016/j.urology.2011.08.063. PMID 22055689.
  5. ↑ Al-Daghistani, Hala I.; Hamad, Abdul-Wahab R.; Abdel-Dayem, Muna; Al-Swaifi, Mohammad; Abu Zaid, Mohammad (2010). "Evaluation of Serum Testosterone, Progesterone, Seminal Antisperm Antibody, and Fructose Levels among Jordanian Males with a History of Infertility". Biochemistry Research International 2010: 1. doi:10.1155/2010/409640.
  6. ↑ Cantatore, C; Capuano, P; Cobuzzi, I; Vacca, M; Coretti, F; Falagario, D; Spilotros, M; Bettocchi, C; Palumbo, F; Depalo, R (2010). "Semen quality and hormonal levels in infertile patients with varicocele". Archivio italiano di urologia, andrologia 82 (4): 291–3. PMID 21341585.
  7. ↑ Mohamad Al-Ali, Badereddin; Marszalek, Martin; Shamloul, Rany; Pummer, Karl; Trummer, Harald (2010). "Clinical Parameters and Semen Analysis in 716 Austrian Patients with Varicocele". Urology 75 (5): 1069–73. doi:10.1016/j.urology.2009.11.042. PMID 20138656.
  8. ↑ Sathya Srini, Vasan; Belur Veerachari, Srinivas (2011). "Does Varicocelectomy Improve Gonadal Function in Men with Hypogonadism and Infertility? Analysis of a Prospective Study". International Journal of Endocrinology 2011: 1. doi:10.1155/2011/916380.
  9. ↑ Li, Fuping; Yue, Huanxun; Yamaguchi, Kohei; Okada, Keisuke; Matsushita, Kei; Ando, Makoto; Chiba, Koji; Fujisawa, Masato (2012). "Effect of surgical repair on testosterone production in infertile men with varicocele: A meta-analysis". International Journal of Urology 19 (2): 149–54. doi:10.1111/j.1442-2042.2011.02890.x. PMID 22059526.
  10. ↑ Hsiao, Wayland; Rosoff, James S.; Pale, Joseph R.; Powell, Jonathan L.; Goldstein, Marc (2013). "Varicocelectomy is Associated with Increases in Serum Testosterone Independent of Clinical Grade". Urology 81 (6): 1213–7. doi:10.1016/j.urology.2013.01.060. PMID 23561709.
  11. ↑ Tanrikut, Cigdem; Goldstein, Marc; Rosoff, James S.; Lee, Richard K.; Nelson, Christian J.; Mulhall, John P. (2011). "Varicocele as a risk factor for androgen deficiency and effect of repair". BJU International 108 (9): 1480–4. doi:10.1111/j.1464-410X.2010.10030.x. PMID 21435152.
  12. ↑ Zohdy, Wael; Ghazi, Sherif; Arafa, Mohamad (2011). "Impact of Varicocelectomy on Gonadal and Erectile Functions in Men with Hypogonadism and Infertility". The Journal of Sexual Medicine 8 (3): 885–93. doi:10.1111/j.1743-6109.2010.01974.x. PMID 20722780.
  13. ↑ Luo, De-Yi; Yang, Gang; Liu, Jian-Jun; Yang, Yu-Ru; Dong, Qiang (2010). "Effects of varicocele on testosterone, apoptosis and expression of StAR mRNA in rat Leydig cells". Asian Journal of Andrology 13 (2): 287–91. doi:10.1038/aja.2010.111. PMC 3739182. PMID 21076439.
  14. 1 2 3 Gat, Yigal; Gornish, M.; Heiblum, M.; Joshua, S. (2008). "Reversal of Benign Prostate Hyperplasia by Selective Occlusion of Impaired Venous Drainage in the Male Reproductive System: Novel Mechanism, New Treatment". First International Journal of Andrologia 40 (5): 273–281. doi:10.1111/j.1439-0272.2008.00883.x. PMID 18811916.
  15. ↑ "Current Management of Adolescent Varicocele". PubMed Central (PMC). Retrieved 2 January 2016.
  16. ↑ Rudloff, Udo; Holmes, Raymond J.; Prem, Jeffrey T.; Faust, Glenn R.; Moldwin, Robert; Siegel, David (2006). "Mesoaortic Compression of the Left Renal Vein (Nutcracker Syndrome): Case Reports and Review of the Literature". Annals of Vascular Surgery 20 (1): 120–9. doi:10.1007/s10016-005-5016-8. PMID 16374539.
  17. 1 2 3 F Yao, David (15-Sep-2015). "Male infertility: lifestyle factors and holistic, complementary, and alternative therapies". Department of Urology, UCLA. doi:10.4103/1008-682X.175779. PMID 26952957. Retrieved 23-March-2016. Check date values in: |access-date=, |date= (help)
  18. ↑ Rehman, Khaleeq ur (Nov 24, 2014). "Varicocele and infertility: Role of pressure flow dynamics". wjgnet. Baishideng Publishing Group Inc. Retrieved March 3, 2016.
  19. ↑ Johnson, A. D. (2012-12-02). Development, anatomy, and physiology. Elsevier. ISBN 9780323143233.
  20. ↑ Eisenberg, Michael L.; Lipshultz, Larry I. (2011-01-01). "Varicocele-induced infertility: Newer insights into its pathophysiology". Indian Journal of Urology : IJU : Journal of the Urological Society of India 27 (1): 58–64. doi:10.4103/0970-1591.78428. ISSN 0970-1591. PMC 3114589. PMID 21716891.
  21. ↑ Song, Gook-Sup (2010-04-01). "Could sperm quality be affected by a building environment? A literature review". Building and Environment 45 (4): 936–943. doi:10.1016/j.buildenv.2009.09.016.
  22. ↑ Kupis Ł, Dobroński PA, Radziszewski P (2015). "Varicocele as a source of male infertility - current treatment techniques". Cent European J Urol 68 (3): 365–70. doi:10.5173/ceju.2015.642. PMC 4643713. PMID 26568883.
  23. ↑ Salam, MA (2013). Principles and Practice of Urology. New Delhi 110 002,India: Jaypee Brothers Medical Publishers. p. 752. ISBN 978-93-5025-260-4.
  24. 1 2 3 Moore, Keith L.; Dalley, Arthur F. (2006). Clinically Oriented Anatomy (5th ed.). Lippincott Williams & Wilkins. p. 228.
  25. ↑ Bucci, Stefano; Liguori, Giovanni; Amodeo, Antonio; Salamè, Leonardo; Trombetta, Carlo; Belgrano, Emanuele (2007). "Intratesticular varicocele: Evaluation using grey scale and color Doppler ultrasound". World Journal of Urology 26 (1): 87–9. doi:10.1007/s00345-007-0216-1. PMID 17962950.
  26. ↑ Charboneau, J. William; Rumack, Carol M; Wilson, Stephanie R. (1998). Diagnostic ultrasound. St. Louis: Mosby. ISBN 0-8151-8683-5.
  27. ↑ Chiles, Kelly A (2016-01-05). "Cost-effectiveness of varicocele surgery in the era of assisted reproductive technology". Asian Journal of Andrology. Asian Journal of Andrology. Retrieved 2016 April 07. Check date values in: |access-date= (help)
  28. ↑ Kupis, Ł; Dobroński, PA; Radziszewski, P (2015). "Varicocele as a source of male infertility - current treatment techniques.". Central European journal of urology 68 (3): 365–70. PMID 26568883.
  29. ↑ Hsu, Geng-Long; Ling, Pei-Ying; Hsieh, Cheng-Hsing; Wang, Chii-Jye; Chen, Cheng-Wen; Wen, Hsien-Sheng; Huang, Hsiu-Mei; Einhorn, E. Ferdinand; Tseng, Guo-Fang (2005). "Outpatient varicocelectomy performed under local anesthesia". Asian Journal of Andrology 7 (4): 439–44. doi:10.1111/j.1745-7262.2005.00080.x. PMID 16281094.
  30. ↑ Costanza, M.; Policha, A.; Amankwah, K.; Gahtan, V. (2007). "Treatment of Bleeding Varicose Veins of the Scrotum with Percutaneous Coil Embolization of the Left Spermatic Vein: A Case Report". Vascular and Endovascular Surgery 41 (1): 73–6. doi:10.1177/1538574406296074. PMID 17277247.
  31. ↑ Kroese, AC; de Lange, NM; Collins, J; Evers, JL (17 October 2012). "Surgery or embolization for varicoceles in subfertile men.". The Cochrane database of systematic reviews 10: CD000479. PMID 23076888.
  32. ↑ Kroese, A. C. J.; De Lange, N. M.; Collins, J. A.; Evers, J. L. H. (2013). "Varicocele surgery, new evidence". Human Reproduction Update 19 (4): 317. doi:10.1093/humupd/dmt004. PMID 23515200.
  33. ↑ Hu, Min; Zhang, Yuehui; Ma, Hongli; Ng, Ernest H. Y.; Wu, Xiao-Ke (2013-07-01). "Eastern medicine approaches to male infertility". Seminars in Reproductive Medicine 31 (4): 301–310. doi:10.1055/s-0033-1345589. ISSN 1526-4564. PMID 23775386.
  34. ↑ Mordel, N; Mor-Yosef, S; Margalioth, EJ; Simon, A; Menashe, M; Berger, M; Schenker, JG (1990). "Spermatic vein ligation as treatment for male infertility. Justification by postoperative semen improvement and pregnancy rates". The Journal of reproductive medicine 35 (2): 123–7. PMID 2406437.
  35. ↑ Evers, Johannes LH; Collins, John A (2003). "Assessment of efficacy of varicocele repair for male subfertility: A systematic review". The Lancet 361 (9372): 1849. doi:10.1016/S0140-6736(03)13503-9.
  36. ↑ Evers, JLH; Collins, JA; Vandekerckhove, P (2001). "Surgery or embolisation for varicocele in subfertile men". Cochrane Database of Systematic Reviews (1): CD000479. doi:10.1002/14651858.CD000479. PMID 11279693.

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