I. Clinical diagnosis
1.Clinical manifestations
Most patients are asymptomatic and are mostly found during physical examination, or painless earthworm-like masses in the scrotum are found during self-examination, or are detected during consultation for infertility. Those who have symptoms mostly show discomfort or pain in the scrotum, and the pain may radiate to the inguinal region and lower abdomen, and the symptoms may worsen after prolonged standing or walking, and may be relieved or disappear after lying down.
2.Auxiliary examination
1.Imaging examination
(1) Ultrasound and color Doppler ultrasonography (recommended) Especially color Doppler ultrasonography can determine the phenomenon of blood reflux in the internal spermatic veins. Non-invasive examination with convenience, good repeatability, high resolution as well as diagnostic accuracy can be the preferred detection method.
(2 ) Infrared scrotal thermometry (optional): non-invasive test. Research shows that the local temperature of scrotum is proportional to the degree of varicose veins, but it is influenced by the temperature of surrounding tissues and environment, and the false positive rate is high.
(3) Spermatic venography (optional):Intraventricular spermography is a reliable diagnostic method. It is divided into three levels.
Mild: Contrast medium reflux in the internal spermatic vein up to 5 cm in length;
Moderate: reflux to the level of the lumbar spine 4-5;
Severe: Contrast flow into the scrotum.
This test is invasive and technically demanding, thus limiting its clinical use. Intravenous spermography can help to reduce the failure rate of high ligation procedures and analyze the causes of surgical failure.
2.Laboratory examination
(1) Semen analysis (recommended) : If immature spermatozoa are detected in semen, abnormal testicular function can be determined.
(2) Anti-sperm antibody test (optional): Patients with infertility should be checked for serum or semen sperm antibodies.
(3) Testicular volume measurement (recommended) In the examination of varicocele, in order to understand whether the testis is damaged and whether it has indications for surgery. The size of the testes must be measured. There are many ways to measure testicular size. These include visual comparison, sizing, Prader molds, Takihara molds, and ultrasound. Most authors agree that ultrasound is the most accurate method of measuring testicular size.
Type
Primary varicocele: Varicocele due to anatomical factors and dysplasia.
2.Subclinical varicocele: It refers to the minor varicocele that cannot be detected during physical examination but can be detected by ultrasound, nuclear scan or color Doppler examination. The diagnosis can be established if the diameter of spermatic vein exceeds 2mm.
3.Secondary varicocele: Intra-abdominal or retroperitoneal tumor, hydronephrosis or ectopic vascular compression of the upstream spermatic veins can also lead to unilateral or bilateral varicocele, which is called secondary varicocele. If the varicocele does not disappear in the lying position, abdominal ultrasound, CT, MRI, etc. should be performed to clarify whether there are related lesions in the affected abdomen.
Grading
Clinically, there are four grades according to the severity:
Grade 0: No symptoms of varicocele, Valsalva test is negative, slight varicocele can be detected by color Doppler examination, and the diameter of the vein is more than 2mm.
Grade 1: Not obvious on palpation, but may be present on Valsalva test.
Grade 2: Dilated veins are highly palpable on palpation but not visible.
Grade 3: Dilated veins can be seen protruding from the scrotal skin when the patient is standing up, like a mass of earthworms, which can be easily palpated.
IV. Histopathological manifestations
The causes of infertility due to varicocele have not been fully elucidated yet, but may be related to the following factors:
(1) Blood stagnation in the spermatic vein, which increases the local temperature of the testis and degenerates the spermatogenic tubules and affects spermatogenesis;
(2) Blood retention affects testicular circulation and CO2 accumulation in testicular tissues, which affects spermatogenesis;
(3) Blood from the left spermatic vein returns to the renal vein, and the metabolites secreted by the adrenal glands and kidneys, such as steroids, catecholamines and 5-hydroxytryptophan, can cause vasoconstriction, resulting in premature sperm shedding;
(4) Varicocele on the left side can affect the function of the right testis, because there are abundant traffic branches of the veins between the testes bilaterally, and the toxins in the blood of the left spermatic vein can affect the spermatogenesis of the right testis.
(5) Immunological factors of spermatic veins, testes and epididymis In recent years, studies have confirmed that infertility of varicocele is related to immunological factors Colomb et al. found the presence of anti-sperm antibodies (ASA) in peripheral blood and semen of infertile varicocele patients ASA enters the testes or epididymis and can interfere with the process of spermatogenesis and sperm maturation, resulting in a decrease in the number of sperm or adhesion to the sperm membrane causing morphological and functional abnormalities of sperm. The ASA may interfere with the process of spermatogenesis and sperm maturation, resulting in a decrease in sperm count or adhesion to the sperm membrane causing morphological and functional abnormalities.
Histopathological changes in the internal spermatic veins are degeneration of the endothelial cells of the vessels, hyperplasia of the intima, hypertrophy of the mesothelium and smooth muscle of the valves, and severe mechanization of the valves, thus causing blood stagnation.
The pathological manifestations of testicular and epididymal injury are detachment of spermatogenic cells, interstitial edema, and small interstitial vascular lesions. Epididymal interstitial edema, epithelial cell degeneration, and disorderly arrangement of brush border on the surface of tubular epithelial cells.
V. Diagnostic format
In clinical practice, the complete diagnosis should include etiology (clinical typing), site, and grading, written with reference to the following format, for example: primary left-sided (right-sided, bilateral) varicocele of the spermatic cord (II°).