Varicocele

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Varicocele
Photo legende d'une Varicocele.jpg
Varicocele on the person's left testicle. Notice the swelling and slight enlargement of the left testicle, which is marked by an arrow.
Pronunciation
Specialty Urology

Avaricocele is, in a man, an abnormal enlargement of the pampiniform venous plexus in the scrotum; in a woman, it is an abnormal painful swelling to the embryologically identical pampiniform venous plexus; it is more commonly called pelvic compression syndrome. In the male varicocele, this plexus of veins drains blood from the testicles back to the heart. The vessels originate in the abdomen and course down through the inguinal canal as part of the spermatic cord on their way to the testis. Varicoceles occur in around 15% to 20% of all men. [3] [4] The incidence of varicocele increase with age.[ citation needed ]

Contents

Signs and symptoms

Varicocele might be noticed as soft lumps, usually above the testicle and mostly on the left side of the scrotum. [5] Right-sided and bilateral varicocele does also occur. Men with varicocele can feel symptoms of pain or heaviness in their scrotum. [5] Large varicoceles present as plexus of veins and may be described as a "bag of worms". [6] [7] Varicocele is sometimes discovered when investigating the cause of male infertility. [8] [9]

Cause

Diagram of spermatic veins Gray1147.png
Diagram of spermatic veins

There are three main theories as to the anatomical cause; the first has to do with the geometry of the veins, wherein the vein on the left side connects to the larger outflowing vein at a right angle, which tends to fail; the second is that testicular valves that are supposed to prevent backflow fail (venous insufficiency) leading to swelling and compression of the valveless pampiniform plexus; the third is due to excessive pressure in upstream veins, created by nutcracker syndrome. [10]

Pathophysiology

Often the greatest concern with respect to varicocele is its effect on male fertility. The relationship between varicocele and infertility is unclear. Some men with the condition are fertile, some have sperm that are normal in shape and move normally but are compromised in function, and some have sperm with abnormal shapes or that do not move well. [10] Theories as to how varicocele affects sperm function include damage via excess heat caused by the blood pooling and oxidative stress on sperm. [4] [10] [11] [12]

Tobacco smoking and mutations in the gene expressing glutathione S-transferase Mu 1 both put men at risk for infertility; these factors may also exacerbate the risk that varicocele will affect fertility. [10]

Diagnosis

Following discovery of the sign of swelling comprising a mass, varicocele can be confirmed with scrotal ultrasound, which will show dilation of the vessels of the pampiniform plexus to be greater than 2,3 mm. [13]

Criteria

A universally accepted system for categorizing varicoceles does not exist, but according to the classification criteria established in 1970 by Dubin and Amelar, most commonly varicoceles are clinically assessed and categorized into three grades as follows: [14] [15]

  1. Grade 1 Varicocele: Characterized by the palpability of the varicocele only when the individual is in a standing position during the Valsalva maneuver.
  2. Grade 2 Varicocele: The varicocele is palpable not only during the Valsalva maneuver but also at rest while standing.
  3. Grade 3 Varicocele: The most severe grade, where the varicocele is not only palpable but also visible through the scrotal skin, without any additional maneuvers.

In the Sarteschi (1993) classification system, varicoceles are categorized into five grades: [16]

  1. Grade I: Reflux occurs solely at the groin level during the Valsalva maneuver, without evident scrotal deformation or testicular atrophy.
  2. Grade II: Reflux is limited to the proximal segment of the pampiniform plexus during the Valsalva maneuver, without scrotal deformation or testicular atrophy.
  3. Grade III: Reflux occurs in the distal vessels located at the lower scrotum exclusively during the Valsalva maneuver, and there is no scrotal deformation or testicular atrophy.
  4. Grade IV: Spontaneous reverse blood flow is present and intensifies during the Valsalva maneuver, resulting in scrotal deformation and the potential for testicular atrophy.
  5. Grade V: Resting reflux is evident within the dilated pampiniform plexus, possibly escalating during the Valsalva maneuver, and is consistently accompanied by testicular atrophy.

Imaging

Manual examination of scrotum is required for proper interpretation of ultrasound images. During ultrasound examination, diameters of veins in pampiniform plexus are measured and regurgitation is measured. The subject is then instructed to stand up and Valsalva maneuver is performed. The diameter is then measured and changes in blood flow direction is recorded to assess any regurgitation. [17]

Treatment

Wound after microsurgical varicocelectomy Wound after microsurgical varicocelectomy.jpg
Wound after microsurgical varicocelectomy

The two most common surgical approaches are retroperitoneal (abdominal using laparoscopic surgery), infrainguinal/subinguinal (below the groin) and inguinal (groin using percutaneous embolization). [4] 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, resulting in a loss of a testicle. [4]

Prognosis

Whether having varicocele surgery or embolization improves male fertility is controversial, as good clinical data is lacking. [9] There is tentative evidence that varicocelectomy may improve fertility in those with obvious findings and abnormal sperm; [4] however, this has a number needed to treat of 7 for varicocelectomy and 17 for embolization. [18] [19] There are also studies showing that the regular surgery has no significant effect on infertility. [9] A 2012 Cochrane review (updated in 2021) found tentative but unclear evidence of improved fertility among males treated for varicocele. [20] Evidence for sclerotherapy is unclear as of 2015. [21]

Epidemiology

Around 15% to 20% of all adult males, up to 35% to 40% of men who are evaluated for male infertility, and around 80% of men who are infertile due to some other cause, have varicocele. [3] [4] [9]

Related Research Articles

<span class="mw-page-title-main">Testicle</span> Internal organ in the male reproductive system

A testicle or testis is the male gonad in all bilaterians, including humans. It is homologous to the female ovary. The functions of the testicles are to produce both sperm and androgens, primarily testosterone. Testosterone release is controlled by the anterior pituitary luteinizing hormone, whereas sperm production is controlled both by the anterior pituitary follicle-stimulating hormone and gonadal testosterone.

<span class="mw-page-title-main">Testicular torsion</span> Medical condition

Testicular torsion occurs when the spermatic cord twists, cutting off the blood supply to the testicle. The most common symptom in children is sudden, severe testicular pain. The testicle may be higher than usual in the scrotum and vomiting may occur. In newborns, pain is often absent and instead the scrotum may become discolored or the testicle may disappear from its usual place.

<span class="mw-page-title-main">Spermatic cord</span> Structure in the human male reproductive system

The spermatic cord is the cord-like structure in males formed by the vas deferens and surrounding tissue that runs from the deep inguinal ring down to each testicle. Its serosal covering, the tunica vaginalis, is an extension of the peritoneum that passes through the transversalis fascia. Each testicle develops in the lower thoracic and upper lumbar region and migrates into the scrotum. During its descent it carries along with it the vas deferens, its vessels, nerves etc. There is one on each side.

<span class="mw-page-title-main">Epididymitis</span> Inflammation of the epididymis, part of the testicle

Epididymitis is a medical condition characterized by inflammation of the epididymis, a curved structure at the back of the testicle. Onset of pain is typically over a day or two. The pain may improve with raising the testicle. Other symptoms may include swelling of the testicle, burning with urination, or frequent urination. Inflammation of the testicle is commonly also present.

<span class="mw-page-title-main">Epididymal hypertension</span> Condition that arises during male sexual arousal when seminal fluid is not ejaculated

Epididymal hypertension (EH), informally referred to as blue balls for males or blue vulva for females, is a harmless but uncomfortable sensation in the genital regions during a prolonged state of sexual arousal. It usually resolves within hours unless relieved through an orgasm.

<span class="mw-page-title-main">Testicular self-examination</span>

Testicular self-examination (TSE) is a procedure where a man examines his own testicles and scrotum for possible lumps or swelling. It is usually undertaken at home while standing in front of a mirror and after having a warm bath or shower. Monthly self-examination of the testicles starting at puberty may be an effective way of detecting testicular cancer at an early, potentially treatable stage, which can lead to a 5-year survival rate of 98%. In men aged 15 to 40, testicular cancer is the most common cancer, and the annual rate of increase over the last 10 years in cases of testicular cancer has been shown to be approximately 1% each year. Testicular cancer typically presents with a painless testicular swelling or lump or any change in shape or texture of the testicles.

<span class="mw-page-title-main">Spermatocele</span> Medical condition

Spermatocele is a fluid-filled cyst that develops in the epididymis. The fluid is usually a clear or milky white color and may contain sperm. Spermatoceles are typically filled with spermatozoa and they can vary in size from several millimeters to many centimeters. Small spermatoceles are relatively common, occurring in an estimated 30 percent of males. They are generally not painful. However, some people may experience discomfort such as a dull pain in the scrotum from larger spermatoceles. They are not cancerous, nor do they cause an increased risk of testicular cancer. Additionally, unlike varicoceles, they do not reduce fertility.

<span class="mw-page-title-main">Testicular atrophy</span> Reduction in the size and function of the testicles

Testicular atrophy is a medical condition in which one or both testicles diminish in size and may be accompanied by reduced testicular function. Testicular atrophy is not related to the temporary shrinkage of the surrounding scrotum, which might occur in response to cold temperature.

<span class="mw-page-title-main">Hematocele</span> Medical condition

A hematocele is a collections of blood in a body cavity or potential space. The term most commonly refers to the collection of blood in the tunica vaginalis around the testes, known as a scrotal hematocele. Hematoceles can also occur in the abdominal cavity and other body cavities. Hematoceles are rare, making them harder to diagnose and treat. They are very common especially as slowly growing masses in the scrotum usually in men older than 50 years.

<span class="mw-page-title-main">Azoospermia</span> Medical condition of a man whose semen contains no sperm

Azoospermia is the medical condition of a man whose semen contains no sperm. It is associated with male infertility, but many forms are amenable to medical treatment. In humans, azoospermia affects about 1% of the male population and may be seen in up to 20% of male infertility situations in Canada.

Male infertility refers to a sexually mature male's inability to impregnate a fertile female. In humans, it accounts for 40–50% of infertility. It affects approximately 7% of all men. Male infertility is commonly due to deficiencies in the semen, and semen quality is used as a surrogate measure of male fecundity. More recently, advance sperm analyses that examine intracellular sperm components are being developed.

An alternative male contraceptive method involves heating the testicles so that they cannot produce sperm. Sperm are best produced at a temperature slightly below body temperature. The muscles around a male's scrotum involuntarily tighten if the man's body temperature drops, and they loosen, allowing the testes to hang, if the body temperature rises. This is the body's way of keeping the sperm at an ideal temperature. This means that sperm production can be disrupted with increased temperature. Some suggest exposure to high temperatures can affect fertility for months.

<span class="mw-page-title-main">Testicular sperm extraction</span> Surgical procedure

Testicular sperm extraction (TESE) is a surgical procedure in which a small portion of tissue is removed from the testicle and any viable sperm cells from that tissue are extracted for use in further procedures, most commonly intracytoplasmic sperm injection (ICSI) as part of in vitro fertilisation (IVF). TESE is often recommended to patients who cannot produce sperm by ejaculation due to azoospermia.

<span class="mw-page-title-main">Testicular vein</span> Blood vessel which drains one of the testicles

The testicular vein, the male gonadal vein, carries deoxygenated blood from its corresponding testis to the inferior vena cava or one of its tributaries. It is the male equivalent of the ovarian vein, and is the venous counterpart of the testicular artery.

<span class="mw-page-title-main">Pampiniform plexus</span> Vein network in the human sex organs

The pampiniform plexus is a venous plexus – a network of many small veins found in the human male spermatic cord, and the suspensory ligament of the ovary. In the male, it is formed by the union of multiple testicular veins from the back of the testis and tributaries from the epididymis.

<span class="mw-page-title-main">Scrotum</span> Sac of skin that protects the testicles

In most terrestrial mammals, the scrotum or scrotal sac is a part of the external male genitalia located at the base of the penis. It consists of a sac of skin containing the external spermatic fascia, testicles, epididymides, and vasa deferentia. The scrotum will usually tighten when exposed to cold temperatures.

<span class="mw-page-title-main">Scrotal ultrasound</span> Medical ultrasound examination of the scrotum.

Scrotalultrasound is a medical ultrasound examination of the scrotum. It is used in the evaluation of testicular pain, and can help identify solid masses.

Male genital examination is a physical examination of the genital in males to detect ailments and to assess sexual development, and is normally a component of an annual physical examination. The examination includes checking the penis, scrotum, and urethral meatus. A comprehensive assessment of the male genitals assesses the pubic hair based on Sexual Maturity Rating and the size of the testicles and penis. The exam can also be conducted to verify a person's age and biological sex. The genitourinary system can also be assessed as part of the male genital examination. During a genital examination, the doctor can detect any of the following: structural abnormalities, urethral opening abnormalities, problems related to not being circumcised, lumps, tumors, redness, excoriation, edema, lesions, swelling, cancer, hair-related issues, and many others. In some instances where a physical examination of the male genitals is not sufficient to diagnose an individual, then an internal genital examination using imaging or ultrasounds will be needed for further evaluation.

Marc Goldstein, MD, DSc (hon), FACS is an American urologist and the Matthew P. Hardy Distinguished Professor of Reproductive Medicine, and Urology at Weill Cornell Medical College; Surgeon-in-Chief, Male Reproductive Medicine and Surgery; and Director of the Center of Male Reproductive Medicine and Microsurgery at New York Presbyterian Hospital. He is Adjunct Senior Scientist with the Population Council's Center for Biomedical Research, located on the campus of Rockefeller University.

Pelvic compression syndrome is characterized by intermittent or persisting pain in the abdomen, which is exacerbated by abdominal pressure. A swelling of the veins in the valveless pampiniform plexus causes it.

References

  1. ↑ "Varicocele". Merriam-Webster.com Dictionary . Merriam-Webster. Retrieved 2016-01-21.
  2. ↑ "Varicocele". Lexico UK English Dictionary. Oxford University Press. Archived from the original on 2020-12-04.
  3. 1 2 White, Wesley M.; Kim, Edward David; Mobley, Joe D (2 January 2019). "Varicocele: Epidemiology". Medscape . Retrieved 18 September 2019. Although varicoceles appear in approximately 20% of the general male population, they are much more common in the subfertile population (40%).
  4. 1 2 3 4 5 6 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. doi:10.5173/ceju.2015.642. PMC   4643713 . PMID   26568883.
  5. 1 2 "Testicular lumps and swellings - Causes - NHS Choices". NHS Choices. 7 October 2014.
  6. ↑ Cannarella, Rossella; Calogero, Aldo E.; Condorelli, Rosita A.; Giacone, Filippo; Aversa, Antonio; La Vignera, Sandro (8 September 2019). "Management and Treatment of Varicocele in Children and Adolescents: An Endocrinologic Perspective". Journal of Clinical Medicine. 9 (8): 1410. doi: 10.3390/jcm8091410 . PMC   6780349 . PMID   31500355.
  7. ↑ Leslie, Stephen W.; Sajjad, Hussain; Siref, Larry E. (7 October 2019). Varicocele. StatPearls [Internet]. PMID   28846314 . Retrieved 20 January 2020.
  8. ↑ "Low sperm count". NHS Choices. 2 August 2016.
  9. 1 2 3 4 Baazeem, Abdulaziz; Belzile, Eric; Ciampi, Antonio; Dohle, Gert; Jarvi, Keith; Salonia, Andrea; Weidner, Wolfgang; Zini, Armand (2011-10-01). "Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair". European Urology. 60 (4): 796–808. doi:10.1016/j.eururo.2011.06.018. PMID   21733620.
  10. 1 2 3 4 Eisenberg, Michael L.; Lipshultz, Larry I. (2011-01-01). "Varicocele-induced infertility: Newer insights into its pathophysiology". Indian Journal of Urology. 27 (1): 58–64. doi: 10.4103/0970-1591.78428 . ISSN   0970-1591. PMC   3114589 . PMID   21716891.
  11. ↑ Hayden, Russell P.; Tanrikut, Cigdem (2016-05-01). "Testosterone and Varicocele". The Urologic Clinics of North America. 43 (2): 223–232. doi:10.1016/j.ucl.2016.01.009. ISSN   1558-318X. PMID   27132580.
  12. ↑ Dabaja, Ali; Wosnitzer, Matthew; Goldstein, Marc (2013-08-01). "Varicocele and hypogonadism". Current Urology Reports. 14 (4): 309–314. doi:10.1007/s11934-013-0339-4. ISSN   1534-6285. PMID   23754533. S2CID   5477034.
  13. ↑ 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.{{cite book}}: CS1 maint: location (link)
  14. ↑ Bertolotto, Michele; Cantisani, Vito; Drudi, Francesco Maria; Lotti, Francesco (September 2021). "Varicocoele. Classification and pitfalls". Andrology. 9 (5): 1322–1330. doi:10.1111/andr.13053. ISSN   2047-2919. PMC   8596817 . PMID   34038625.
  15. ↑ A. Hamada; et al. (2016). Varicocele and Male Infertility (PDF). SpringerBriefs in Reproductive Biology. doi:10.1007/978-3-319-24936-0. ISBN   978-3-319-24934-6. S2CID   5203944.
  16. ↑ Namdev, Rupesh. "Varicocele grading on color Doppler | Radiology Reference Article | Radiopaedia.org". Radiopaedia. Retrieved 2023-10-04.
  17. ↑ Lorenc T, Krupniewski L, Palczewski P, Gołębiowski M (December 2016). "The value of ultrasonography in the diagnosis of varicocele". Journal of Ultrasonography. 16 (67): 359–370. doi:10.15557/JoU.2016.0036. PMC   5269523 . PMID   28138407.
  18. ↑ Kroese, A. C. J.; Lange, N. M. de; Collins, J. A.; Evers, J. L. H. (2013-07-01). "Varicocele surgery, new evidence". Human Reproduction Update. 19 (4): 317. doi:10.1093/humupd/dmt004. PMID   23515200.
  19. ↑ 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. S2CID   20329833.
  20. ↑ Persad, Emma; O'Loughlin, Clare Aa; Kaur, Simi; Wagner, Gernot; Matyas, Nina; Hassler-Di Fratta, Melanie Rosalia; Nussbaumer-Streit, Barbara (2021-04-23). "Surgical or radiological treatment for varicoceles in subfertile men". The Cochrane Database of Systematic Reviews. 2021 (4): CD000479. doi:10.1002/14651858.CD000479.pub6. ISSN   1469-493X. PMC   8408310 . PMID   33890288.
  21. ↑ Macleod, R; Biyani, CS; Cartledge, J; Eardley, I (13 July 2015). "Varicocele". BMJ Clinical Evidence. 2015. PMC   4500994 . PMID   26168774.
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