Varicocele is the stagnation of blood flow in the spermatic veins resulting in the trapezius plexus (plexus of veins, abnormal elongation, dilation and tortuosity) of the spermatic cord.
I. Prevalence
The prevalence of varicocele is 10-15% of the male population, mostly in young adults, of which 21-41% are seen for infertility. This disease occurs mostly on the left side, but bilateral onset is not uncommon, but in recent years it has been found that the incidence of bilateral varicocele can reach more than 40% of this disease. Varicocele rarely occurs in prepubertal teenagers.
Etiology and pathology
The spermatic veins are composed of internal and external spermatic veins and vas deferens veins, and the three groups of veins communicate with each other in the scrotum and form the spermatic plexus.
The trailing spermatic plexus formed by the testicular and epididymal veins converges into 1-2 internal spermatic veins in the inguinal canal and continues upward in the retroperitoneum. The left spermatic vein enters the left renal vein at a right angle, while the right enters the inferior vena cava at an acute angle about 5 cm below the right renal vein. The external spermatic vein consists of the levator muscle vein, which leaves the spermatic vein at the outer ring of the inguinal canal from, enters the inferior abdominal wall vein, superior abdominal wall vein, superficial pubic vein and deep pubic vein, and finally converges into the external iliac vein. The vas deferens vein enters the pelvis with the vas deferens at the internal ring of the inguinal canal and merges into the internal iliac vein.
The veins in the spermatic cord are long, so if the valves are poorly developed, damaged or incomplete and the smooth muscle or elastic fibers in the walls of the veins are weak, the internal pressure may increase and the blood flow may be blocked, making varicocele easily occur. The reasons for the high incidence of left spermatic varicose vein: 1. The left spermatic vein is 8-10 cm longer than the right, and the venous pressure on the left side is greater than that on the right side. 2. The right common iliac artery may compress the left common iliac vein, blocking the return of the left vas deferens vein, forming the so-called distal clamping phenomenon. 6.The left internal spermatic vein may be compressed by the distended sigmoid colon. 7.The spermatic vein itself is diseased: weakness of the vein wall and its surrounding connective tissue or underdevelopment of the levator muscle. 8.The upright posture of a person affects the spermatic venous reflux
Intra-abdominal or retroperitoneal tumors, hydronephrosis, or heterogeneous vessels compressing the upstream spermatic vein can also cause poor blood return, which can lead to varicocele. Especially in kidney tumor, in addition to its own mechanical compression, may also occur in the renal vein or inferior vena cava cancer embolism, resulting in varicose veins.
The mechanism of infertility caused by varicocele is not clear, nearly 40% of infertile men have varicocele, and about half of them have improved semen test results after surgery. Infertility caused by varicocele may be related to the following factors:1. Blood stagnation in the spermatic vein increases the local temperature of the testis and degeneration of spermatogenic tubules affects spermatogenesis; 2. Blood stagnation affects testicular blood circulation and CO2 accumulation in testicular tissue affects spermatogenesis; 3. Blood from the renal vein returning from the left internal spermatic vein will metabolites secreted by the adrenal glands and kidneys such as steroids, Catecholamines, 5-hydroxytryptamine, etc. to the testes, steroids can inhibit spermatogenesis, catecholamines can make the testes chronic poisoning, 5-hydroxytryptamine 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 rich traffic branches of the veins between the testes bilaterally, the toxins in the left spermatic veinology English can affect the spermatogenesis of the right testis.
Usually, semen examination should be routinely performed for patients with varicocele in clinical practice. The results show that most patients have decreased sperm count, decreased sperm motility, increased number of immature and acromegalic sperm, and in severe cases, no sperm.
Studies on histological changes in the testis of patients with varicocele have revealed desquama-tion of the spermatogenic epithelium of the varicocele, disturbed arrangement of spermatogonia and spermatocytes, and a progressive decrease. In severe cases, spermatogonia were lost and only supporting cells (Sertoli cells) remained, and multinucleated giant cells were seen. The walls of the seminiferous tubules are glassy, the lumen is constricted, some of the Leydig cells in the interstitium are regressed and others are hyperplastic, and there are sclerotic changes in the vessels. Sperm production disorders mainly occur in the primary spermatocyte and spermatocyte stages, and are more obvious on the affected side.
Clinical manifestations
History: primary varicocele may have a history of male infertility; secondary varicocele may have a history of primary disease such as kidney tumor and hydronephrosis.
Symptoms: mainly the affected side of the scrotum is distended when standing, there is a local feeling of swelling and pain, which can radiate to the lower abdomen, groin or waist, and the symptoms are mostly aggravated after exertion and prolonged standing, and reduced or disappeared after lying down and resting. The degree of varicose veins and symptoms may not be consistent, sometimes accompanied by neurological symptoms.
Signs: When standing, one side of the scrotum is distended, the testicles are drooping, and worm-like varicose veins are visible or palpable. When the scrotum is lying down or held up, the dilated vein mass shrinks and fills up again in the upright position. Secondary varicocele does not shrink in the standing position and sometimes enlarged kidneys can be palpated.
IV. Symptoms
Patients with obvious signs and symptoms are easy to diagnose. The degree of varicocele is usually clinically classified into three degrees: degree 1: the varicose veins are not palpable locally, but can be palpated when the patient holds his breath and increases abdominal pressure; this test is called the Valsalva test; degree 2: the varicose veins can be palpated in the normal standing position, but have a normal appearance; degree 3: the varicose veins are visible on the surface of the scrotum, and soft earthworm masses can be gouged on palpation.
Primary varicocele can disappear in the horizontal position, but if it does not disappear, secondary varicocele should be suspected. In this case, careful examination of the ipsilateral lumbar abdomen and B-mode ultrasound, IVU or CT or MRI should be performed to determine whether the disease is caused by retroperitoneal tumor or renal tumor compression.
The Valsalva test is also negative, but minor varicocele can be detected by ultrasound, nuclear scan or color Doppler examination. The diagnostic criteria for subclinical varicocele have not been standardized, but it is generally accepted that a venous duct diameter of more than 2 mm is considered subclinical varicocele and more than 5 mm is considered clinical varicocele.
Varicocele examination methods include Doppler ultrasound auscultation, infrared contact scrotal thermometry, real-time B-mode ultrasonography, radioisotope 99mTc scrotal blood pool scan, selective renal vein and internal spermatic venography, etc. Internal spermatic venography is a reliable diagnostic method. It is performed under local anesthesia with the Seldinger method via femoral vein cannulation into the internal spermatic vein. The results of the imaging can be classified into three degrees: mild: contrast reversal in the internal spermatic vein up to 5 mm in length; moderate: contrast reversal to the level of L4-5; and moderate: contrast reversal into the scrotum. This method can be used to diagnose varicocele and guide the treatment, but this method is after all an interventional diagnostic tool, which is not particularly needed clinically and is generally not advocated to be carried out universally.
V. Differential diagnosis
I. Filariasis spermatorrhea
In acute attacks, severe pain in the scrotum radiating to the lower abdomen or lumbar region, or dull pain and lumbar discomfort, and hard nodules with tenderness may appear around the lower end of the spermatic cord or vas deferens. The nodal pathology may show granulomas infiltrated by worms and eosinophils and lymphocytes.
2. Filarial lymphatic varicose veins
There is a history of recurrent filarial spermatorrhea, with discomfort and swelling in the scrotum, aggravated by activity, scrotal swelling, thick, twisted and dilated spermatic cords. There is a smaller mass of cords in the lower part of the spermatic cord, which is evident with activity and standing, and decreases with rest and recumbency. The early transillumination test is positive and may be negative in old cases. Microfilariae can be found in the peripheral blood after sleep.
Tuberculosis of vas deferens and epididymis
The scrotum is swollen and uncomfortable, the vas deferens is thickened and changed into bead-like hard nodes, the tail of the epididymis is irregularly enlarged and hardened, hard nodes can be palpated, and in some patients, the epididymis is hard connected to the scrotum and forms purulent sinus tracts.
VI. Treatment
Non-surgical treatment: For those who have no symptoms or mild symptoms, non-surgical treatment is recommended, such as scrotal brace, local cold compress and avoiding pelvic and perineal congestion caused by excessive sexual life.
Surgical treatment: If the symptoms are serious enough to affect daily life and workers or if the symptoms are not relieved by non-surgical treatment, surgical treatment should be performed. Those with significant varicocele or abnormal semen or with infertility should also be considered as indications for surgery.
In the past, it was thought that some patients with mild varicose veins might resolve on their own after sexual maturity, so mild varicose veins without symptoms and without affecting fertility could be left untreated. As the research on subclinical varicocele progresses, it is believed that subclinical varicocele can also affect testicular function, therefore, patients with all types of varicocele should be actively treated. Some even advocate that adolescents with varicocele should undergo surgery as soon as possible to avoid affecting their future fertility (Haselberger, 1982,).
Traditional treatment is based on open surgery. The surgical principle is to ligate and cut the internal spermatic vein at a high level at the level of the retroperitoneal, internal inguinal canal ring. Usually an oblique inguinal incision is used to perform a high ligation of the internal spermatic vein and to remove part of the dilated vein in the scrotum. In cases of combined male infertility, a testicular biopsy is preferable.
Sexual internal spermatic vein embolization has also been reported for the treatment of varicocele, but it is not widely used because it requires special equipment and techniques, and there is a risk of spillage of the embolic agent into the circulatory system. In addition, spermatic vein diversion and spermatic muscle duct folding are also available.
The surgical routes are.
There are mainly two routes: retroperitoneal via the iliac fossa and inguinal canal, and the addition of a shunt is not necessary. The reasons for surgical failure are mostly due to missed venous branches and injury to the internal spermatic artery.
1. Trans-iliac fossa retroperitoneal spermatic vein high ligation
There are two types of spermatic cord ligation: preservation of testicular artery and Palmo procedure. The Palmo procedure is simple and does not require identification of the spermatic cord arteries and veins, and there are no reports of testicular atrophy.
In cases of varicocele with testicular atrophy, testicular atrophy may be reversed only after successful surgery, and testicular atrophy cannot be reversed in those with postoperative recurrence. Therefore, a failed spermatic vein ligation can cause more damage to the testes than a high cut off of the testicular artery. Therefore, although varicocele is a minor surgery, it requires a delicate surgical operation to achieve its ideal therapeutic purpose, so it is vital to choose a surgeon with extensive experience to perform the surgery for it.
The most effective treatment for infertility caused by varicocele is a high level ligation of the internal spermatic vein. Previously, the entire spermatic vessels were ligated, but nowadays the tendency is to free and protect the spermatic arteries, especially if the aim is to restore fertility, but this is not done by a significant number of medical personnel for technical reasons.
Minimally invasive needle laparoscopic ligation of the spermatic veins
Laparoscopic spermatic vein ligation, this procedure has the advantages of minimal trauma and quick recovery.
Patients with varicocele must follow the following indications and contraindications for surgery so that they do not suffer from physical and mental trauma again.
1.Indications
1, varicocele infertility, the presence of abnormal semen examination, medical history and physical examination did not find other diseases affecting fertility, normal endocrine examination, female fertility examination without abnormal findings, regardless of the severity of varicocele, as long as the diagnosis of varicocele once established, should be timely surgery.
2.Severe varicocele with obvious symptoms, such as more standing that is to feel the pain of scrotal swelling, etc., physical examination found that the testicles are obviously shrinking, even if there is fertility, the patient has a desire for treatment can also be considered for surgery.
3, clinical observation found that the incidence of prostatitis, seminal vesiculitis in varicocele patients increased significantly, twice as much as normal people, so if the above two diseases exist at the same time, and prostatitis is not cured for a long time, there are also advocated to do varicocele surgery.
4, for adolescent varicocele, because it often leads to pathological and progressive changes in the testicles, it is currently advocated that adolescent varicocele with testicular volume reduction should be treated with surgery as early as possible, which can help prevent infertility in adulthood.
5.For patients with mild varicocele, if the semen analysis is normal, they should be followed up regularly. Once there is abnormal semen analysis, testicular shrinkage and softening of texture, surgery should be performed promptly.
2.Contraindications
1.Secondary varicocele.
2.Primary varicocele if the lateral branch reflux is poor with lateral branch reflux.
2.Tranguinal route
The recurrence rate after traditional transinguinal spermatic vein ligation is 5% to 45%, and the incidence of syringomyelia is 3% to 39%, and the possibility of testicular artery injury is also greater.
The rate of semen improvement after surgery for varicocele infertility can be 50% to 80%, and the overall pregnancy rate can be 25% to 31%, more than double the 12% rate for those without surgery. There are many factors that affect the semen improvement rate as well as the pregnancy rate, which are related to age, disease duration and the quality of semen before surgery. If the preoperative sperm count is >10×109/L, the postoperative semen improvement rate is 85% and the pregnancy rate can reach 70%; if the preoperative sperm count is <10×109/L, the semen improvement rate is only 35% and the pregnancy rate is only 27%. The possibility of restoring fertility after surgery in azoospermia is very low. Varicocele with infertility or semen abnormalities is an indication for surgery regardless of the severity of the symptoms. Some people even advocate early surgery in adolescence to avoid affecting future fertility. If the symptoms of varicocele are not obvious and the patient has normal fertility, surgery is not necessary.
Since the left renal vein is an important pathological change when varicocele is present, it is not ideal to remove the varicose seminiferous plexus from the scrotum only. The main reason for surgical failure is missed branches of the vein. The spermatic artery must be carefully stripped and preserved.
3.Interventional treatment
Some people insert a catheter through the inferior vena cava and left renal vein to the left internal spermatic vein, and then inject 5% sodium cod liver oil or gelatin sponge with steel ring to embolize this vein to treat varicocele.
Disadvantages: if the vein is malformed and there is collateral circulation, varicocele is a common disease in young men, generally about 10% of young men will have varicocele and more than 90% are located on the left side. Varicocele is a pathological phenomenon in which the trailing veins of the spermatic cord become dilated, tortuous, and elongated due to poor reflux from various causes. Many patients with varicocele have a combination of oligozoospermia and azoospermia, which affects fertility.
Evaluation of postoperative results
The recovery of fertility after varicocele treatment is primarily related to the degree of reversibility of testicular damage and does not necessarily parallel the degree of the original varicose veins. The majority of people treated with high level ligation of the internal spermatic vein have better results, and the semen quality has improved to different degrees, while the few who have no improvement in semen quality are mainly irreversible damage to the original spermatogenic function, in addition to incomplete surgical ligation of veins and misligation of arteries. It is reported that six months to one year after the surgical ligation treatment, the semen quality has significantly improved about 50% to 85%, and the conception rate is 30% to 70%. Therefore, in order to improve the post-operative conception rate of varicocele, it is crucial to choose an experienced surgeon. Because the degree of damage to the testicular sperm production by varicocele cannot be changed before surgery, it is variable to choose an experienced surgeon in order to improve the cure rate.