Varicocele (VC) is a common genitourinary disorder in men and a major cause of male infertility. It is mostly seen in young adults, with an incidence of 10% to 15% of the normal male population and 19% to 41% of male infertility. Varicocele is a vascular spermatogenic disorder caused by the expansion of the spermatic veins and trabecular plexus that surround the spermatic cord. It is more common on the left side, but can also occur bilaterally or singly on the right side.
Most prevalent group: young and middle-aged men
Common causes
Dilatation of the spermatic veins and trabecular plexus
Etiology
The disease is a vascular disease characterized by varying degrees of dilatation and tortuosity of the trabecular plexus in the spermatic cord. It can be classified as primary or secondary VC by etiology. Primary VC may be caused by increased intravascular pressure, the left spermatic vein travels long and converges at right angles to the left renal vein, superior mesenteric artery and aorta to compress the left renal vein, affecting the left internal spermatic vein reflux, which is known as “Nutcracker” phenomenon (NCS), weak connective tissue around the internal spermatic vein and venous valve dysfunction and incomplete closure. It is caused by anatomical factors such as weak connective tissue around the internal spermatic vein and venous valve dysfunction, incomplete closure, abnormal tissue structure of the spermatic vein wall, anatomical variation of the spermatic vein, and underdevelopment of the levator muscle. Secondary causes of VC may include intra-abdominal or retroperitoneal tumors, hydronephrosis, and ectopic vascular compression of the superior spermatic veins.
Clinical manifestations
Patients are often not treated in time due to the lack of self-perceived symptoms, which eventually leads to impaired spermatogenesis in some patients. A small number of patients may have scrotal swelling and localized painful swelling in the standing position, which may radiate to the lower abdomen, groin area or posterior lumbar region, and the symptoms may worsen after exertion or prolonged standing, and reduce or disappear after lying down and resting.
Examination
The use of staining methods and morphological analysis of sperm in strict accordance with WHO standards can help evaluate the degree of fertility impairment in infertile patients, and also facilitate the standardization of operation and unification of analysis standards. Therefore, for patients with low sperm density, low viability, low vitality, and high malformation rate shown by routine semen examination, color Doppler flow imaging (CDFI) examination is recommended. CDFI can visually and accurately observe the degree of dilatation of varicocele and the state of blood flow, and is currently a non-invasive and accurate diagnostic route. Infrared scrotal thermometry or spermatic venography are also available.
The clinical diagnostic criteria of CDFI are
1.Clinical type VC
At least three or more spermatic veins are detected in the spermatic plexus under calm breathing, and the inner diameter of one of them is >2.0mm or increases significantly when the abdominal pressure is increased, or the venous blood reflux is obvious after the Valsalva test;
2.Subclinical VC
Spermatic vein intima ≥1.8mm, no blood reflux with calm breathing, reflux with Valsalva test, reflux time phase ≥800ms.
Diagnosis
The more accurate diagnostic method currently used is color Doppler flow phenomenon.
Treatment
Surgical treatment is the main treatment method and can achieve the desired therapeutic effect. Some of them are also treated with (or combined with) drugs.
Secondary factors such as renal tumor, hydronephrosis, retroperitoneal tumor, and ectopic vessels should be excluded first.
Primary VC with infertility or semen abnormality is an indication for treatment regardless of the severity of symptoms. Currently, surgical treatment includes microscopic spermatic vein ligation, trans-inguinal canal spermatic vein high ligation, laparoscopic spermatic vein high ligation, etc.
The degree of improvement in semen parameters and pregnancy rate of those treated by surgery combined with medication are significantly better than those treated by surgery alone.