Extract: “Treatment of varicocele is generally chosen firstly by medication, and when medication is ineffective or the condition seriously affects the patient’s daily life and sexual function as well as fertility, surgery may be chosen.”
Varicocele is a dilated, tortuous and elongated vasculature of the spermatic trapezius plexus (plexus of veins) caused by stagnation of blood flow in the spermatic veins, commonly seen in young adults. The incidence of this disease is about 10%-15% in the normal population and accounts for 15%-20% of the causes of male infertility. Clinically, there are two types of varicocele: primary and secondary.
Primary varicocele mostly occurs at the age of 15-30 years, presumably the scrotum and its contents are rich in blood supply during this period, and excessive sexual stimulation can reflexively cause pelvic and intra-seminomatous venous congestion, which leads to the occurrence of varicocele. Secondary varicocele is caused by obstruction of blood flow in the spermatic vein on its way back to the spermatic cord, mostly over the age of 35. Common lesions that compress the spermatic vein include: renal tumors, ureteral tumors, retroperitoneal tumors, hydronephrosis, iliac vein obstruction, pelvic tumors, etc.
Clinical diagnosis: grading + exclusion
Patients with varicocele have increased local temperature, hypoxia, pH change, and retention of toxic substances due to the accumulation of venous blood flow in the scrotum and other parts of the scrotum, which then affects the spermatogenesis of the testes and leads to a decrease in the number of sperm, decreased sperm motility, and an increase in the proportion of malformed sperm, thus reducing male fertility and leading to male infertility. Some patients feel discomfort in the scrotum, mainly manifesting as a feeling of swelling in the scrotum and testicles, wet and cold scrotum, swelling and vague pain, mostly radiating to the ipsilateral perineum, groin and lumbar region, with symptoms aggravated after exertion, prolonged walking and sexual intercourse. In addition, some patients may have insomnia and dreaminess, mental depression, fatigue, decreased libido, and erectile dysfunction.
Clinically, varicocele can be diagnosed by physical examination, color ultrasonography, and spermatic venography.
Physical examination: clinically, varicocele can be divided into 3 degrees by palpation. 1 degree (mild): no varicose veins protrude from the scrotal skin when standing, but varicose veins can be palpated in the scrotum, and the varicose veins disappear quickly when lying down; 2 degree (moderate): dilated veins protrude from the scrotum when standing, and more obvious varicose veins can be palpated in the scrotum, and the mass gradually disappears when lying down; 3 degree (severe): scrotal surface There are obvious thick blood vessels and obvious worm-like dilated veins in the scrotum, the walls of the veins are hypertrophied and hardened, and disappear slowly when lying down.
Color ultrasonography: can assess the degree of varicocele and help to exclude other diseases (such as tumors or inflammatory nodules, vascular malformations, hernias or syringomyelia).
Spermatic venography: At present, spermatic venography is the most reliable method to diagnose varicocele. It can determine the presence or absence of varicocele, its degree and the presence of anatomical variants, and provide clear diagnostic information, but its clinical application is somewhat limited because it is an invasive test that requires corresponding operations and higher costs.
Treatment: choose drugs before surgery
According to Prof. Qiu Yongchao, varicocele is very common in clinical practice, but not all patients need to be treated, but only when the following conditions occur
A . Patients have more serious clinical discomfort, such as painful scrotal swelling and moist feeling.
B . B . the patient’s fertility is affected by varicocele, such as decreased sperm quality on semen examination
C . C . The sexual function of the patient is affected by varicocele, such as impotence, premature ejaculation, painful intercourse, etc.
D . Varicocele in children affects their testicular development.
Professor Qiu Yongchao said that the treatment of varicocele is divided into medical treatment and surgical treatment, “Generally, medication is chosen first, and only when medication is ineffective, surgery is considered.” In addition, generally mild varicocele does not lead to infertility, but some severe cases can affect the spermatogenic function due to poor blood circulation to the testicles, which can lead to infertility. These can be evaluated in advance by semen tests to assess fertility and if, after analysis, infertility is deemed to be due to varicocele, treatment (medication or surgery) is required to restore fertility. Before undergoing treatment, the patient should first be relieved of the psychological burden caused by excessive anxiety, which can be of great benefit.
Medication + testicular belt: Professor Qiu Yongchao talked about that since there are many causes of varicocele, some patients may be difficult to be completely cured by medication only and need surgery to cure; however, some patients are able to improve the discomfort symptoms and be cured gradually by taking medication. “Clinically, vitamin E can be used to protect and promote the spermatogenic function of the testicles, Diosmin or herbal rhinoceros fluid tablets to improve varicose veins, and pancreatic kininogenase tablets to promote blood circulation to the testicles and protect the spermatogenic function of the testicles.”
Professor Qiu Yongchao reminded, “The treatment of general varicocele takes 3 months as a course of treatment. After 3 months of medication, the effect of treatment will be judged by color ultrasound, semen examination and patient’s feeling, and it will be decided whether it is necessary to continue medication or switch to surgery. In addition, if 2 courses of medication (about 6 months) do not work and the disease is found to have seriously affected the patient’s daily life, sexual function and fertility, surgery can be considered.”
The function of the testicular band is to lift the scrotum, thus reducing symptoms such as scrotal swelling, and also to promote venous blood return to the scrotum. For those who are asymptomatic or have mild symptoms, tight underwear can be worn to achieve the same effect. In addition, during the treatment period, patients should be advised to avoid overexertion, sedentary, proper exercise, abstain from smoking, alcohol and light diet, etc.
Surgery: If medication does not work or if the condition seriously affects the patient’s daily life and sexual function as well as fertility, surgery may be an option. High level ligation of the internal spermatic vein, i.e. ligation of all the branches of the internal spermatic vein at the inner ring, should be avoided during the operation and lead to recurrence. After the ligation of the internal spermatic vein, the venous blood returning from the testes and parametrium can be returned to the inferior vena cava along the external spermatic vein. Alternatively, the internal spermatic vein can be ligated at the posterior peritoneal space above the internal ring, where there are fewer branches of the internal spermatic vein (especially on the left side) and can be avoided by missing ligation. The advantage of this procedure is that the arteries, veins, nerves and lymphatic vessels in the spermatic cord can be distinguished, and the veins can be ligated and cut while the arteries, nerves and lymphatic vessels are preserved, thus avoiding postoperative complications such as testicular atrophy, chronic pain and scrotal edema.
Interventional embolization is to inject embolic material, such as gelatin sponge, spring steel wire or sclerosing agent, selectively or super-selectively into the internal spermatic vein through a catheter to occlude the varicose vein, which can avoid postoperative complications such as scrotal edema and hematoma, but it is not easily carried out in primary hospitals because of the need for appropriate techniques and equipment.
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Differential diagnosis points
Secondary varicocele Most of them are secondary to retroperitoneal tumor and hydronephrosis. The molluscum-like varicose vein mass in the scrotum cannot be rapidly reduced or disappeared after lying down, and urography or CT or MRI should be performed to help differential diagnosis.
Scrotal hematoma The swelling of scrotal hematoma with grayish purple or petechiae, obvious pressure pain without varicose veins of this disease, mostly with history of trauma or surgery, and blood may be available on puncture. Color ultrasonography can help in differential diagnosis.
Sphingomyelomeningocele Swollen scrotum with cystic mass, smooth surface, soft and fluctuating, no pressure pain, no adhesion with scrotal skin, testes and epididymis not easily palpable, positive transillumination test, fluid can be extracted by puncture. Color ultrasound examination can help in differential diagnosis.