Overview
I. Definition
Varicocele is an abnormal dilatation, elongation and tortuosity of the trabecular plexus in the spermatic cord.
II. Epidemiology
The prevalence of varicocele (VC) in the general male population varies depending on the method of evaluation. It is about 15% in the general male population and 20% to 40% in infertile men [1]. The disease is most often seen in adult males, while it is relatively rare in adolescents. The prevalence is 2% to 11% before puberty [2-4] and 15% to 16% after puberty [5]. Domestic literature reported that the overall incidence of varicocele in adolescents aged 6 to 19 years was 10.76% [6].
Varicocele is a vascular lesion that is usually seen on the left side, accounting for about 85% to 90% of cases [6] and 10% of cases bilaterally, with the right side being more often seen in bilateral lesions and rare in those occurring on the right side alone.
WHO ranked varicocele as the first cause of male infertility [7]. According to the literature, the incidence of VC is 35% in primary infertility and 80% in secondary infertility, and the disease is significantly more prevalent in first-degree relatives, with varicocele found in 21.1% of fathers and 36.2% of brothers [8].
III. Etiology
Anatomically, the testicular and epididymal veins converge into a trapezoid plexus, which returns via three pathways: (1) in the inguinal canal to form the internal spermatic vein, which travels upward in the retroperitoneum, with the left internal spermatic vein entering the left renal vein at a right angle and the right entering the inferior vena cava at an acute angle about 5 cm below the right renal vein, with about 5% to 10% entering the right renal vein directly; (2) via the vas deferens vein to the internal iliac vein; (3) via the levator muscle vein to the inferior abdominal wall vein and converge into the external iliac vein.
Varicocele occurs with the following factors: (1) the upright posture of the person affects the venous reflux; (2) the weakness of the venous wall and its surrounding connective tissue or the underdevelopment of the levator muscle; (3) the role of the venous valve in preventing the blood flow back, when the absence or poor function of the spermatic vein valve can lead to blood reflux. In addition, varicocele is more common in the left spermatic vein than in the right side, and the possible reasons are: (1) the left internal spermatic vein has a long stroke and enters the renal vein at a right angle, which increases the venous pressure; (2) the left internal spermatic vein may be compressed by the sigmoid colon; (3) the left renal vein may be compressed between the aorta and superior mesenteric artery, which affects the reflux of the left spermatic vein (called proximal clamp phenomenon, Buga’s syndrome); (4) the right common iliac artery may compress the left common iliac vein, blocking the return of part of the left spermatic vein (known as the distal clamp phenomenon) [7].
In addition, diseases such as retroperitoneal tumors may affect the reflux of the spermatic veins, leading to the development of secondary spermatic varicose veins [9].
Pathophysiology
I. Effects on fertility
A large number of clinical and experimental studies have been conducted on the mechanisms by which varicocele leads to male infertility. It is commonly believed that VC is associated with semen abnormalities, testicular volume reduction, decreased testicular perfusion and testicular spermatogenic dysfunction. However, the exact mechanism causing infertility has not been reliably proven so far and is thought to be related to the following factors: (1) High temperature: Under normal conditions, a counter-flow heat exchange cooling system exists between the testicular arteries and veins. When varicocele is present, due to blood stagnation, it can cause decreased efficiency of heat exchange in the trabecular plexus and increased temperature in the scrotum and testes, leading to spermatogenesis disorders and decreased testosterone synthesis by testicular interstitial cells; (2) hypoxia: poor venous blood return caused by varicocele increases venous pressure and aggravates varicocele, which can lead to testicular stasis and hypoxia and induce germ cell apoptosis; (3) adrenal metabolite reflux. Metabolites secreted by the adrenal glands and kidneys such as steroids, catecholamines, 5-hydroxytryptamine, etc. can flow backwards along the internal spermatic veins to the testes, causing adverse effects on testicular metabolism; (4) other: VC-related pathologies including increased reproductive toxins, increased levels of antioxidants, reduced DNA polymerase activity, presence of sperm-binding immunoglobulins, reduced testicular spermatogenic cells, germ cell apoptosis and other comprehensive Physiological changes may eventually lead to testicular growth arrest and atrophy [10-11].
Studies have shown that varicocele is a progressive disease that can cause impaired testicular growth and gradual decline in testicular function, leading to infertility. Repair of varicocele repair can stop or even reverse this process, and 80% of infertile men can improve semen quality by repairing varicocele [12].
In conclusion, the current research on pathophysiological changes in male infertility caused by VC has advanced to the ultrastructural and molecular levels. However, abnormal testicular spermatogenesis due to VC is an intricate pathological process, which is likely to be the result of a combination of factors.
Second, the effect on pain
The incidence of varicocele pain is 2%-10% [13-14], which mainly manifests as persistent or intermittent pulling, cramping, vague and dull pain in the scrotum, evident when standing and walking, and relieved after lying down and resting [15]. The mechanism of its occurrence is unclear and may be related to the compression of the sensory branches of the ilioinguinal nerve and genitofemoral nerve by the pull of the varicose veins and the stagnation of blood in the seminiferous veins causing increased temperature and tissue ischemia [16].
III. Effects on androgens
The effect of varicocele on androgens is controversial, with some studies suggesting a decrease in serum testosterone levels in patients with varicocele [17] and others concluding the opposite [18]. It has also been reported in the literature that surgical treatment of VC increases androgen levels in patients [19-22], while another such report showed that surgery did not increase blood testosterone levels in patients [23-24]. However, a recent randomized controlled study demonstrated that varicocele significantly decreased serum total testosterone levels in patients and that there was a significant increase in serum total testosterone postoperatively [25]. Mechanistically, this may be due to the increased apoptosis of testicular mesenchymal cells prompted by VC [26-27], which leads to a decrease in the expression of steroidogenetic acute regulatory (StAR) protein, the rate-limiting enzyme of testosterone synthesis [27].
In addition, localized testosterone can cause intra-seminomatous venous diastole by activating ATP-dependent activation of potassium channels, which may contribute to the progressive increase in the prevalence of varicocele after puberty [28].
Classification and grading
I. Classification by etiology
1. primary form
It is mostly seen in young adults and most of them have left-sided onset.
2. secondary type
It is varicocele caused by obstruction of spermatic vein reflux due to compression by renal tumor or vena cava tumor embolism, retroperitoneal tumor, pelvic tumor, hydronephrosis, renal cyst and ectopic vascular compression.
Second, according to the age classification
1.Adult type
Age 19 years old (above).
2.Adolescent type
Age between 10~18 years old.
C. Classification by physical examination
1.Subclinical type
The spermatic cord cannot be palpated and the patient cannot find the varicose veins when holding the breath to increase the abdominal pressure (Valsalva test). However, minor varicose veins can be detected by color Doppler examination.
2.Clinical type I
The spermatic cord is not obvious on palpation, but the patient can find the varicose vein when increasing the abdominal pressure (Valsalva test).
3.Clinical type II
The spermatic cord can be palpated and the varicose spermatic vein can be found.
4.Clinical type III
The varicose veins in the scrotum can be seen, and the spermatic cord can be palpated to reveal a significantly increased, varicose vein mass.
D. Color Doppler ultrasound (CDFI) grading
At present, the grading standards of color Doppler ultrasound (CDFI) at home and abroad are not consistent, which may be related to the different ethnic groups in Asia and Europe.
The CDFI criteria for diagnosing spermatic varicoceles are generally accepted in China as meeting the following conditions: (1) the maximum internal diameter (DR) of the spermatic vein during calm breathing ≥1.8 mm; (2) the maximum internal diameter (DV) of the spermatic vein during Valsalva maneuver ≥2 mm; (3) positive Valsalva maneuver, i.e., color and spectral Doppler measurement of reflux signal and duration of (TR) ≥ 1s [29].
The grading criteria for the diagnosis of seminiferous varicosities by CDFI [30]: according to the clinical and ultrasound diagnosis, seminiferous varicosities can be classified into four degrees: subclinical, clinical type I, II and III.
1. subclinical type of varicocele: negative clinical palpation and reflux in the spermatic vein on ultrasound, DR 1.8~2. 1 mm, TR 1-2 s.
2. clinical varicocele degree I: positive clinical palpation and DR 2.2-2.7 mm, TR 2-4 s on ultrasound.
3. clinical varicocele II: positive clinical palpation and DR 2.8~3.1 mm on ultrasound, TR 4~6 s. Clinical varicocele II: positive clinical palpation and DR 2.8~3.1 mm on ultrasound, TR 4~6 s.
4. clinical varicocele III: positive clinical palpation and ultrasound DR ≥ 3.1mm, TR ≥ 6s.
V. Grading under intra-seminomegaly
Some domestic scholars classify varicocele into three degrees according to the results of intravesical spermography.
1. mild: the length of contrast agent reflux in the internal spermatic vein up to 5 cm.
2. moderate: reflux of contrast medium to the level of lumbar vertebrae 4 to 5
3. severe: the contrast agent refluxes into the scrotum.
Diagnosis
I. Medical history (Medical history) (recommended)
1. Varicocele is usually asymptomatic and is mostly found during routine physical examination, or painless earthworm-like masses in the scrotum during self-examination, or during consultation for infertility. However, some patients may have symptoms such as scrotal swelling, hidden pain and discomfort. During history taking, attention should be paid to these symptoms related to testicular atrophy index, and whether the symptoms worsen after prolonged standing or walking; whether the mass can be relieved and reduced or disappear after lying down; and the duration of symptoms. Whether there are other vascular diseases (e.g. varicose veins in the lower limbs, hemorrhoids). Patients with testicular pain can be assessed semi-quantitatively using scales such as the visual analogue scale or the pain numerical scale.
Very painful Not painful
Visual analogue scale
10 9 8 7 6 5 4 3 2 1 0
Very painful Not painful
Pain numerical score
2. Marital history: whether infertile, how long without contraception without pregnancy. Whether the woman has ever been made pregnant.
3, Past history.
4, history of surgery, history of trauma. Note any previous history of kidney surgery. Because there are reports showing a significant increase in the diameter of the trapezius plexus after left nephrectomy [31].
Second, physical examination (Physical examination) (recommended)
1, The patient’s body type, note that the lean and long type is noted to be differentiated from secondary VC.
2.Physical examination methods of varicocele
Methods: (1) Visual examination: observe whether there are tortuous veins in the scrotal skin; (2) examine when standing; (3) examine after lying down; (4) examine after Valsalva action.
3.Examination of testes, epididymis and vas deferens
(1) Testicular size can be measured with the Prader testicular model or compared with the healthy testicle. In adults and adolescents, the size of both testes should be approximately the same, and the difference should not exceed 2 ml or 20% of the volume [32]. (2) Epididymis and vas deferens: other possible causes of infertility (e.g., congenital vas deferens) should be noted in patients with VC who present for infertility.
Laboratory examination
1. Semen examination (recommended)
Semen examination is recommended for those who are infertile or have fertility requirements. Given the fluctuations in semen quality, two consecutive semen examinations within 3 months are recommended, and the tests should include: semen volume, liquefaction time, pH, sperm density, and motility [33].
2. serum androgens (total testosterone, free testosterone, sex hormone binding globulin) [34] (recommended)
Serum total testosterone is recommended, and serum free testosterone or bioactive testosterone is also feasible in units where available, or free testosterone can be calculated from serum total testosterone, sex hormone binding globulin and albumin levels by the Vermeulen formula described below [35] or the small software available on the International Society for the Study of Aging Men website.
3. serum follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), and estrogen (E) [36] (optional)
4. serum inhibin B [37-38] (optional)
5. gonadotropin-releasing hormone (GnRH) test (not recommended) [39-41]
There is no evidence that the GnRH test is helpful in the diagnosis, treatment selection and prognosis of patients with varicocele.
Imaging examination
1. Color Doppler ultrasonography (recommended)
Color Doppler ultrasonography is of great value for the diagnosis and staging of varicocele [42]. The use of scrotal ultrasound can detect more patients with subclinical type of seminiferous varicoceles in infertile patients [43]. The tests and diagnostic methods are as follows.
a Determination of the internal diameter of the spermatic vein (DR) during the calm breathing test and the internal diameter of the spermatic vein (DV) during the Valsalva maneuver.
bReflux: duration of reflux (TR) at rest and during Valsalva maneuvers.
There is still controversy as to which indicator is more meaningful, venous reflux seen on ultrasound or internal diameter of the spermatic veins, with some studies suggesting that reflux is more meaningful than internal diameter [44], while others suggest that measurement of internal diameter alone is sufficient [45].
cTestis, epididymis (recommended)
d left renal vein, inferior vena cava (optional, only considered in case of unremitting varicocele in the horizontal position, advanced age or severe VC in adolescents)
eDiagnostic criteria and grading criteria of color multispectral ultrasound as described in the previous classification and grading section.
2. CT, MRI (not recommended)
Generally not recommended, optional for secondary varicocele in search of etiology and differential diagnosis.
3. Angiography (optional)
Internal spermatic venography helps to reduce the failure rate of high ligation surgery and to analyze the causes of surgical failure. The specific operation is to perform angiography under local anesthesia via femoral and jugular vein cannulation to the internal spermatic vein. The grading criteria are described in the classification and grading section.
V. Other tests
Testicular biopsy, generally not recommended, is only applicable to a small number of special patients.
Differential diagnosis
Varicocele can be diagnosed basically by physical examination and ultrasonography. However, because of the uncertainty of its relationship with scrotal discomfort, pain, fertility, and androgen, attention should be paid to identify whether varicocele is combined with other diseases that cause the above symptoms, especially psychological disorders with physical symptoms as the main manifestation. The diagnosis of varicocele should be made along with the identification of primary or secondary varicocele.
Evaluation of testicular spermatogenic function
At present, the impact of varicocele is mainly on fertility, therefore, the accurate evaluation of testicular spermatogenic function will be of great significance for treatment.
1. Size and texture of the testis.
The more severe the varicocele and the longer the onset of the varicocele, the smaller and softer the testicle will be. Smaller and softer testicles are also a sign of testicular insufficiency. Testicular texture is largely influenced by subjective factors, but testicular size can be measured by the Prader testicular gauge [46] or color ultrasound multispectroscopy. Compared to testicular volume measured by ultrasound, testicular volume is usually overestimated with the Prader testicular meter, especially in the case of small testes [47]. A testicular volume of 20 mL or more on ultrasound suggests normal testicular function [48], whereas a testicular volume of 30-35 mL with the Prader testicular gauge suggests normal testicular function [49]. In adolescent patients with varicocele, testicular size can be measured using vernier calipers and the testicular atrophy index can be calculated. The length, width and thickness of the testes were measured bilaterally in the affected children using vernier calipers. The formula for calculating testicular volume [50]: testicular volume (ml) = testicular length (mm) × width (mm) × thickness (mm) × 0.521 The measured testicular volume can also calculate the testicular atrophy index (AI), and the atrophy index = (right testicular volume to left testicular volume) / right testicular volume × 100%, and testicular atrophy can be considered when the index is >15%.
2. Semen examination
The quality of semen reflects to a certain extent the degree of damage to the spermatogenic function of the testis. Patients with varicocele may present with oligospermia, hypospermia, oligozoospermia, aberrant spermia, and even azoospermia [51].
3. serum FSH, LH, PRL, and inhibin B
Serum FSH is a better indicator for evaluating testicular spermatogenic function, and lower serum FSH levels suggest better testicular spermatogenic function, which also predicts a better treatment effect [52]. It has been suggested that FSH and LH correlate well with testicular spermatogenic function in adolescent patients with varicocele and can be used to evaluate their testicular spermatogenic function [40]. Some studies have shown that serum inhibin B can more accurately evaluate testicular spermatogenic function compared to FSH can be used as a predictor of postoperative spermatogenic function changes [53].
4. testicular biopsy, which is generally not recommended, is used only when testicular spermatogenic function cannot be adequately evaluated despite the use of the above methods.
Treatment and follow-up
Treatment of primary varicocele should be differentiated according to whether the patient is associated with infertility or abnormal semen quality, the presence or absence of clinical symptoms, the degree of varicose veins and the presence or absence of other complications. Treatment methods include surgical and non-surgical treatment, and most of the literature reports that surgical treatment is the main treatment. Secondary varicocele should be actively searched and treated for the original disease.
I. Surgical treatment.
(A) Indications for surgery.
1. The recommended indications for surgery in adult clinical type patients are as follows.
(1) The following three conditions are present at the same time [7,54-57].
(1) Presence of infertility.
(2) Decreased spermatogenic function of the testes.
(3) Normal fertility in the female partner, or possible cure despite infertility.
(2) Those with abnormal semen quality on examination despite a temporary absence of fertility requirements [55-56].
(3) If the symptoms associated with varicocele (such as swelling and pain in the perineum or testicles) are severe and significantly affect the quality of life, and if improvement is not obvious with conservative treatment, surgery may be considered [7,15,57-64].
(4) Those with II or III degree varicocele varicocele and significantly decreased blood testosterone levels, excluding those due to other diseases.
2. For patients with subclinical varicocele, surgery is generally not recommended [54-55]; however, for patients with clinical varicocele on one side and subclinical varicocele on the other side, bilateral surgery is recommended when surgery is indicated [65-66].
3. Indications for surgery for adolescent-type varicocele [40,50,54-55,58,67-77].
(1) Second- or third-degree varicocele.
(2) Decreased spermatogenic function of the testes (see the section on evaluation of testicular function for details).
(3) Those with more severe associated symptoms caused by varicocele.
(4) Varicocele in childhood and adolescence should be actively sought for the presence of primary disease.
(ii) Surgical modality.
The significance of varicocele in male infertility, the value of surgical intervention, and the advantages and disadvantages of various intervention modalities are still controversial, but the technique of spermatic vein repair is still one of the most common surgical treatments for male infertility. Interventional approaches for varicocele repair include surgical treatment and interventional techniques (cis or retrograde). Surgical interventions include traditional transinguinal, retroperitoneal, and subinguinal spermatic vein ligation, microtechnical inguinal or subinguinal spermatic vein ligation, and laparoscopic spermatic vein ligation. Some data suggest that microtechnical spermatic vein ligation is the most ideal treatment modality [78-79], but microsurgery requires special surgical instruments, special training for the surgeon, high surgical costs, and long operative time, which makes it unsuitable for large-scale promotion in primary care hospitals.
Safe and effective surgery for varicocele repair should comply with the following points: ① maintain the integrity of the vas deferens and its vascular system ② free and ligate all internal spermatic veins and, if a trans-inguinal incision is used, also ligate the branches of the external spermatic veins ③ maintain the integrity of the lymphatic vessels and arteries [80].
1. comparison of different surgical approaches (see Table 1)
(1) Microsurgery: microscopic technique of spermatic cord vein ligation is superior to other methods in terms of overall assessment of postoperative complication rate, improvement in semen parameters, and conception rate, probably due to the microscopic identification of testicular arteries, lymphatic vessels, and veins with smaller diameters [81].
(2) Laparoscopic internal spermatic vein ligation: it has advantages such as the possibility of simultaneous management of bilateral lesions, but is more invasive and costly. The recurrence rate of laparoscopic spermatic vein ligation is 2% to 11%, and there is about 5-8% occurrence of postoperative edema [82-83].
(3) Interventional techniques: including both cis and retrograde techniques, this method is more commonly used by interventionalists. Embolization can be achieved by gelatin sponges, spring coils and sclerotherapy. It has a low recurrence rate and no postoperative edema occurs, but is complex and costly, and is only considered when dealing with recurrent spermatic varicoceles in that the anatomy needs to be clarified by imaging [82].
2. Comparison of surgical access routes
(1) Transinguinal route and subinguinal route: these include the traditional open procedure and the microscopic technique. However, these two routes are currently used mainly for microscopic techniques. The transinguinal subinguinal incision for spermatic vein ligation is considered superior to the transinguinal route because it does not require incision of the external oblique abdominal tendon membrane, is less painful, causes less injury, and has a faster postoperative recovery. The latter is particularly advantageous in patients who are obese, have undergone previous inguinal approach and have a high external ring position. The transinguinal route is relatively simple and time-consuming in terms of anatomical features, and it is less difficult to protect the testicular artery [84]. In addition, the protection of the testicular artery is particularly important in patients with monorchidrosis, so the transinguinal route is also preferable.
(2) Retroperitoneal route: i.e. Palomo’s procedure, which consists of preservation of the testicular artery and cluster ligation without preservation of the artery. This procedure is more convenient, but the recurrence rate can be 10% to 15%.
In summary, the choice of treatment modality should take into full consideration the conditions of the hospital, the expertise and experience of the operator, and the wishes of the patient.
(iii) Surgical complications.
The common complications after spermatic vein ligation are mainly postoperative edema, testicular artery injury and recurrence of varicocele, and the above table more objectively compares the incidence of complications of various procedures and routes.
Edema is the most common complication after spermatic vein ligation, with an incidence of 3 to 39% and an average of 7%, and lymphatic vessel injury or misligation is the main cause of edema.
2. Testicular artery injury Most of the postoperative testicular atrophy occurs due to ligation or injury to testicular artery during surgery, and the overall incidence of testicular atrophy is about 0.2%.
The recurrence of varicocele is thought to be due to missed ligation of the genital branch of the internal spermatic vein, the external spermatic vein, and the leading vein. The recurrence rate after spermatic vein ligation is 0.6% to 45%. Available studies have shown a low recurrence rate for microscopic spermatic vein ligation by the subcircular route [85].
4. others Laparoscopic surgery can lead to serious complications such as pelvic and abdominal organ and vascular injuries.
(iv) Management of surgical recurrence.
The indications for reoperation should be in accordance with the general surgical indications, and depending on the operator’s habits and surgical history, traditional open techniques, microscopic techniques, laparoscopic techniques and simultaneous embolization by intravenous spermography can be used [85-88].
It is recommended that in the section on surgical treatment, members of the writing group are collectively asked to carefully and comprehensively review the relevant literature on varicocele surgery, carefully discuss it, and extensively solicit opinions to objectively describe the issues regarding its surgical method selection, efficacy, and complication analysis. Because this part is one of the most important parts of this guideline, it is important to respect the evidence-based medical basis, fully consider the national situation and the current situation of clinical treatment, and exclude personal subjective opinions. Avoid unnecessary controversies in future clinical work due to the guidelines.
For example, the number of cases of each surgical modality in the above table (comparison table of the efficacy of different treatment modalities for varicocele) is so small that it is impossible to make a statistical comparison, and it is arbitrary and even misleading to conclude the difference of which procedure (efficacy, complications) based on this information. It is felt that the literature selected by the authors is somewhat biased and a comprehensive search of the relevant literature is recommended?
The above opinions are personal and for reference only.
Second, drug treatment
Is it possible to describe in two parts (drugs to improve symptoms and drugs to improve semen quality), because the first part (drugs that have an effect on varicocele vessels) only describes the mechanism of the latter part of the drugs, can it be combined into the last two parts? In addition, the wording of “drugs that act on varicocele vessels” – drugs that act on blood vessels – does not seem to be particularly smooth, so please consult the writing team]
(A) Drugs that act on varicocele blood vessels
1. heptaosaponin: such as mai zhi ling (omega chestnut seed extract, its main component is heptaosaponin), can reduce capillary permeability, eliminate tissue swelling and edema, also can protect the collagen fibers of the venous wall, gradually restore the elasticity and contraction function of the diseased venous wall, improve the tension and strength of the wall, also can directly act on the intravascular cell receptors, cause venous contraction, increase venous blood flow back It also has a direct effect on intravascular cellular receptors, causing venous contraction, increasing venous blood return and decreasing venous pressure, thus improving the symptoms caused by varicocele [92-93]. It also improves semen quality in some patients with varicocele.
2. Bioflavonoids: It has been shown that these drugs can reduce the intravascular diameter of subclinical varicocele, reduce the development of subclinical varicocele into symptomatic varicocele, and improve the symptoms of perineal pain caused by varicocele to some extent, but cannot stop the testicular growth arrest that has already started [89-91].
(ii) Adjuvant drugs to improve symptoms
1. non-steroidal anti-inflammatory drugs, such as anti-inflammatory pain, ibuprofen, cinnoxicam, etc. Some studies have shown that these drugs can alleviate the symptoms related to varicocele caused by spermatocele to a certain extent and can also improve their semen quality in some patients [94-96].
2. bioflavonoids: as mentioned before, they can improve the symptoms of perineal pain caused by varicocele to a certain extent [89-91].
(iii) Drugs that aid in improving semen quality
Personally, I think it is better to list them here, because the guidelines are mature one and one comes out first. If the guide of varicocele comes out first, we must keep this part, such as the guide of infertility comes out first or two guides come out at the same time, we can refer to the guide of male infertility.
Third, other adjuvant therapies
including cooling therapy [97-100], lifestyle and dietary modifications [101-103], psychological interventions [104-110], and scrotal support [17,111], may benefit patients to some extent.
IV. Follow-up.
(a) Adult patients without surgical treatment, with normal semen quality and fertility requirements, should be followed up at least once every 1-2 years, including history questioning, volumetric examination, ultrasound of scrotal contents, semen analysis, and pain score [54-56].
(b) Pediatric and adolescent patients without surgical treatment should be followed up at least once a year if the testes are normal in size, and the follow-up should include history taking, volume examination, ultrasound of scrotal contents, semen analysis, and pain score [54-56,67].
(iii) For patients who underwent surgery, the first follow-up visit can be performed 1-2 weeks after surgery, mainly to check for any surgery-related complications; the second follow-up visit is performed 3 months after surgery and every 3 months thereafter, for at least 1 year or until successful conception, with follow-up including medical history questioning, volume examination, ultrasound of scrotal contents, semen analysis, and pain score [54-56,67].
(iv) During the treatment and follow-up of patients with varicocele with infertility, attention should be paid not only to the male patient but also to the female partner, such as her fertility status, age, and other factors, and the wishes of both partners in terms of fertility should be fully considered [54-56,112-116].
Communication with the patient
I. Communication with the patient during the diagnosis
The diagnosis of varicocele is not difficult through history, physical examination and ultrasound, but the patient should be clearly informed of the inevitable link between varicocele and patient’s fertility, patient’s pain and other symptoms, and patient’s decreased testosterone level cannot be clarified at present.
Second, communication with the patient when grasping the indications for surgery
Patients with indications for surgery must be fully informed of the existence of some uncertainty about the outcome of surgery to patients and/or their families before surgery [54-56,67]: these include.
(1) For patients presenting for infertility, the patient and his or her spouse should be fully informed that there may be postoperative outcomes such as insignificant improvement or even decline in semen quality and failure to improve infertility; at the same time, the wishes of the couple in terms of fertility should and be fully considered, and other optional treatments should be informed on going, such as assisted reproductive technologies.
(2) For patients who visit the clinic due to symptoms associated with varicocele, they should fully inform themselves or their parents or guardians that there may be cases of insignificant improvement of symptoms, insignificant recovery of testicular size, or insignificant improvement of semen quality after surgery, and that there is still a possibility of infertility in the future.
(3) For patients who visit the clinic with significantly decreased blood testosterone level, the patient should be fully informed that there may be a situation that the relevant symptoms do not improve significantly or even further aggravate after surgery.
(3) Communication with the patient when choosing the surgical method
The surgeon can make a full discussion and communication with the patient about the choice and pros and cons of various treatment modalities, taking into account the medical conditions of the doctor’s hospital and based on his own judgment and experience, as well as the doctor’s best treatment means.
1. The medical conditions and level of the doctor’s hospital.
2. the doctor’s own experience and best surgical modality.
3. the pros and cons of different surgical modalities
4. the possible complications of the surgery.