In the urology waiting room, a tall, strong man clutching his medical record and frowning, wandered in front of the triage office, his face showing indefinable embarrassment and hesitation. The nurse greeted him with a smile and asked the patient for advice. The gentleman’s face suddenly turned red and he stammered, “Scrotal pain …….” Under the arrangement of the nurse, the gentleman soon met with the doctor and explained his situation: It turned out that the gentleman was 30 years old and had felt pain in his scrotum for several years, but he had not been concerned about it. He had been feeling pain in his scrotum for a few years, but had not been concerned about it. Later, he noticed that the pain in his scrotum had increased and became more pronounced when he stood up and moved around, but he had not sought medical attention because he was embarrassed. After the doctor arranged a series of tests for the gentleman, he was diagnosed with varicocele. When this term, which is so specialized, was put in front of Mr., he was even more puzzled. Varicocele is a common disease in urology, the incidence of which accounts for about 10-15% of the male population and is mostly seen in young adults. Many patients do not know enough about this disease, and the treatment is not timely, causing serious consequences. In this issue, we invited Dr. Jiang Hualong from urology department to answer our questions about varicocele! Reporter: Hello, Dr. Jiang! It is known that some teenagers suffer from varicocele, what exactly is varicocele? Dr. Hualong Jiang: Varicocele actually refers to varicocele, which is the abnormal elongation, expansion and tortuosity of the trapezius plexus of the spermatic vein caused by the reflux and stasis of blood in the spermatic vein. In severe cases, they may accumulate in the scrotum in the form of masses, causing scrotal swelling and discomfort. Reporter: How do varicose veins in the spermatic cord cause? Dr. Jiang Hualong: The main reason is that the veins in the spermatic cord are long, and if the venous valves are underdeveloped, damaged or incomplete and the smooth muscle or elastic fibers of the vein walls are weak, the internal pressure increases and the blood return is obstructed, making varicose veins easy to occur. Reporter: If you have varicocele, how should you treat it? Dr. Jiang Hualong: Varicocele can cause continuous and irreversible damage to the testicles, and there are traffic branches in the testicles bilaterally, so varicocele on the left side will not only affect the left testicle, but also the right testicle. The latest opinion is that in order to prevent irreversible damage to the testicles, varicocele should be operated on as soon as it is detected. For those who have symptoms such as scrotal swelling and hidden pain, those who have varicocele and abnormal semen or infertility, and those who have varicocele combined with prostatitis and vesiculitis, surgery should be performed in time. In general, varicocele will affect the spermatogenic function of the spermatogenic epithelium of the testicular varicocele and cause infertility. The effect on the interstitium of the testis is less, but there is also the possibility of affecting androgen production and sexual function. Therefore, patients with clearly diagnosed varicocele should be treated surgically in time. In the past, it was thought that some patients with mild varicoceles might resolve on their own after sexual maturity, so mild varicoceles, which are asymptomatic and do not affect fertility, could be left untreated. As the research on subclinical varicocele has intensified, it is believed that subclinical varicocele can also affect testicular function, therefore, patients with various types of varicocele should be treated actively. Some people even advocate that adolescents should undergo surgery as soon as varicocele is detected so as not to affect their future fertility. Reporter: Why does varicocele cause infertility? Dr. Jiang Hualong: Infertility caused by varicocele may be related to the following factors: 1, the retention of blood in the spermatic vein, which increases the local temperature of the testis, and the degeneration of spermatogenic tubules affects the occurrence of sperm; 2, the retention of blood affects the blood circulation of the testis, and the accumulation of CO2 in the testicular tissue affects the occurrence of sperm; 3, the blood of the renal vein that returns from the left internal spermatic vein, and the 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 chronically toxic, 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 of the left spermatic vein blood 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. Reporter: So what is the best surgical procedure for varicocele? Will it recur? Dr. Jiang Hualong: At present, the best surgical procedure is “retroperitoneal spermatic vein high ligation”, the key to decide whether the surgical result is good or bad is whether the spermatic artery can be found and all the veins can be ligated, because there are three components in the spermatic cord: the spermatic vein (can be one or more), the spermatic artery and the lymphatic vessels, find and preserve the spermatic artery and ligate all the veins. The best result of the procedure is to ligate all the veins, preserving the arteries, ensuring the blood supply to the testes and the return of the blood through the external spermatic veins. The ligation of all the internal spermatic veins blocks the return of metabolic wastes such as catecholamines and 5-hydroxytryptophan in the renal venous blood, restoring the normal blood supply to the testes and the epididymis, in order to restore the function of the testes to the greatest extent. As for the recurrence, the internal spermatic vein is a plexus of veins in the scrotum, which converges into 1-2 branches in the inguinal canal and continues upward in the retroperitoneum, and the left internal vein of the spermatic cord enters the left renal vein at right angles. Therefore, theoretically, the possibility of complete ligation of all the internal veins of the spermatic cord is the greatest in retroperitoneal surgery. However, in practice, it is found that in most cases more than two spermatic veins are found during retroperitoneal surgery, and there may be some tiny veins that cannot be identified by the naked eye, or they may not be detected during surgery because they are surrounded by lymphatic vessels, or they are close to the arteries and not easily detected. Therefore, there is a possibility of missing a vein during the surgery, and if there is a missed vein, there is a possibility of recurrence. Generally speaking, the key to recurrence after surgery is whether all the internal spermatic veins are ligated during surgery. If there is a residual internal spermatic vein, there is a possibility of recurrence after surgery. Generally, the ultrasound will be repeated after 6 months after surgery to determine whether there is recurrence. Reporter: Can varicose vein patients have fertility after having high spermatic vein ligation? Doctor: Spermatozoal vein ligation only removes the factors that cause damage to the testicles, after the operation, the blood flow of the testicles is normal, and then the function of fertility will slowly improve. It takes about 72 days for sperm to develop to maturity, so if it is effective after surgery, it usually takes 3 months after surgery to show up in semen analysis. There are many causes of infertility, varicocele being only one of the major factors. The mechanism of infertility caused by varicocele is not well understood, nearly 40% of infertile men have varicocele, and more than half of them have improved semen test results after surgery. Reporter: I heard that “ligation” is done for contraceptive purposes, but after “ligation” you can’t have children, so why do infertile patients need “ligation” surgery? Doctor: The “ligation” we mentioned here refers to the “internal spermatic vein ligation”, which is to tie the internal spermatic vein, not the vas deferens. The term “ligation” that many people used to hear for contraception refers to “bilateral vasectomy”. The two are completely different concepts. I believe that after reading the interview, you will have a new understanding of varicocele. However, no matter which disease it is, it is important to consult your doctor in time to understand the condition and receive reasonable treatment, and never avoid the disease. Thank you Dr. Hualong Jiang for your kind answer! The best surgical procedure for varicocele – “high level ligation of retroperitoneal spermatic vein with preservation of testicular artery”.