Varicocele (VC) is one of the common clinical diseases in male medicine, and has received widespread attention because of its associated scrotal pain and discomfort, infertility and testicular atrophy, especially its impact on fertility. This article compiles the diagnosis and treatment of varicocele based on the relevant content and recommendations of the Chinese Expert Consensus on the Diagnosis and Treatment of Varicocele, in the hope of helping clinicians make decisions about the diagnosis and treatment of this disease.
Most men who visit the male clinic at the Center for Reproductive Medicine will encounter a doctor who examines the scrotum. This physical examination includes testicular size, epididymis size, tenderness, the presence of bilateral vas deferens, and the condition of the spermatic cord, of which the most important item is the presence of thickened spermatic veins. Therefore, the diagnosis of varicocele is mainly based on the physical examination and ultrasound, but the treatment plan is determined according to the patient’s age, fertility, semen quality, and local scrotal symptoms.
Clinicians most commonly use physical examinations to grade varicocele (clinical type).
Degree 1: The thickened spermatic cord cannot be palpated when the patient is breathing calmly, but can be felt when doing breath-holding maneuvers to increase abdominal pressure.
Degree 2: The varicose veins are directly palpable in the scrotum in the standing position with calm breathing.
Degree 3: The varicose veins can be seen directly on the surface of the scrotum (e.g. worm-like). During physical examination, it should also be noted that a smaller and softer testicle is a sign of testicular insufficiency.
Grading under color ultrasonography.
Degree 1 (subclinical type): It is not palpable on clinical physical examination, and the diameter of the vein is 1.8~2.1mm on ultrasound under calm breathing, but there is no reflux in the vein. There is reflux only during increased abdominal pressure movements.
Degree 2 (clinical type degree 1): the thickened spermatic vein in the scrotum can be palpated clinically, and the diameter of the spermatic vein is 2.2~2.7mm measured by ultrasound, and there is reflux when increasing abdominal pressure, which lasts 2~4 seconds.
Degree 3 (clinical type degree 2): the thickened spermatic vein in the scrotum can be felt clinically, and the diameter of the spermatic vein is 2.8~3.1mm as measured by ultrasound, and there is reflux when increasing abdominal pressure, and the duration is 4~6 seconds.
Degree 4 (clinical type 3): the diameter of the vein is 3.1mm on calm breathing examination, there is reflux on increasing abdominal pressure, and the duration is 6 seconds.
In addition to the above physical examination and ultrasound measurement of the internal diameter of the veins to assess the degree of varicocele, attention should also be paid to semen quality, sex hormone levels, testicular size, etc. to determine the comprehensive treatment plan.
(1) General treatment: including lifestyle and dietary regulation and physical therapy, such as: abstaining from smoking and limiting alcohol, eating a light diet, avoiding exercises that increase abdominal pressure; cooling therapy or scrotal support, etc.
(2) Drug treatment.
a. Drugs for varicocele.
Hepta saponins: such as mai zhi ling, anti-inflammatory, anti-exudation, protection of collagen fibers of the vein wall, can gradually restore the elasticity and contraction function of the vein wall, increase the speed of venous blood return, reduce venous pressure, thus improving the symptoms caused by varicocele.
Flavonoids: anti-inflammatory and antioxidant effects can improve venous tone, reduce capillary permeability, increase lymphatic return rate and reduce edema; improve the painful symptoms caused by clinical type varicocele.
b. Drugs to improve symptoms: for local pain and discomfort, non-steroidal anti-inflammatory drugs, such as ibuprofen, can be used.
c. Drugs to improve semen treatment: For patients with varicocele who have combined reproductive function impairment and have fertility requirements, drugs to promote spermatogenesis and improve semen treatment can be used, such as choosing appropriate vitamins, tamoxifen, and proprietary Chinese medicines.
(3) Surgery: If the effect of drug treatment is not obvious, surgery can be considered. The significance of varicocele in male infertility, the value of surgical treatment, and the advantages and disadvantages of various treatment modalities are still in disagreement. The surgical treatment of varicocele includes surgical ligation of varicose veins and interventional embolization. The surgical treatment includes traditional transinguinal, retroperitoneal, subinguinal spermatic ligation, microtechnical inguinal or subinguinal spermatic ligation, laparoscopic spermatic ligation, etc. The choice of treatment should take into account the specific circumstances of the disease, the conditions of the hospital, the expertise and experience of the surgeon, etc.
Finally, it is recommended that male patients with varicocele should visit and consult the male department of a reproductive medicine center that specializes in fertility. Urology tends to focus on surgical treatment and the assessment of fertility is lacking, and many times the patient’s postoperative sperm quality does not improve or is even worse, and the indications for surgery are broader.