Varicocele is a common disorder of young adults in which the veins in the spermatic cord are coiled and varicose, forming a worm-like plexus in the scrotum. Depending on the pathogenesis, varicocele is generally divided into primary varicocele and secondary varicocele, where secondary varicocele is caused by compression of the spermatic veins on the way of venous blood return, mostly over the age of 35;
The common compression lesions are: renal tumor, ureteral tumor, retroperitoneal tumor, hydronephrosis, perinephric pus accumulation, iliac vein obstruction, etc. Since secondary varicocele is only a symptom of the primary disease, the treatment is mostly based on the treatment of the primary disease. The primary varicocele, also known as idiopathic varicocele, the cause of which is not very clear, is the main character we are talking about today.
I. Epidemiology
Regarding the incidence of primary varicocele, there is a big difference in the incidence statistics due to the different natural conditions and populations of the statistical studies, generally speaking, the incidence of varicocele in men is 10-15% of the male population, this disease occurs mostly on the left side, but bilateral onset is not uncommon. The biggest danger of varicocele is that it leads to testicular atrophy and sperm production disorder, causing male infertility, according to statistics, varicocele may be the causative factor for 40% of male infertility patients.
Second, the pathogenic mechanism
Up to now, the mechanism of male infertility caused by varicocele has not been completely clarified, but the research results show that it may be related to the following factors.
1, scrotal temperature: varicocele, due to the depressed blood flow in the spermatic vein, can cause the scrotal temperature to rise, an average of 0.6 ℃ above normal, thus affecting sperm production.
2. Nutritional disorders: Due to the depressed venous blood flow, the blood circulation of testes and epididymis is affected, and the supply of nutrients and oxygen required by them is lacking, which affects spermatogenesis.
3, testicular endocrine dysfunction: due to the local temperature rise in the scrotum, the testicular blood supply and oxygen supply is insufficient, which inevitably affects the endocrine function of the interstitial cells in the testicular varicocele, thus interfering with spermatogenesis.
4, the role of toxins: because there is a rich side branch circulation between the spermatic vein and testicular vein, when varicose veins occur, causing blood countercurrent, can be carried in the left adrenal gland and the left renal vein blood high concentration of toxic metabolites, such as steroids, catecholamines, 5-hydroxytryptamine and prostaglandins, before detoxification that flow into the bilateral testes, so that spermatogenesis is affected, resulting in different degrees of spermatozoa, too little The sperm production is affected, resulting in different degrees of spermatozoa, abnormal shape and movement disorders.
5, the destructive effect of oxygen free radicals: some studies have shown that when varicocele occurs, oxygen free radicals increase in testicular tissue and lipid peroxidation increases, thus affecting the occurrence of spermatozoa and sperm function.
Third, anatomical features
The spermatic veins are formed by the confluence of the veins of the testes, epididymis and vas deferens. These veins form a spreading plexus within the spermatic cord and merge upward into the inguinal canal to form several branches of the internal and external spermatic veins. In about 60% of cases, the internal spermatic veins merge into a single branch at the internal ring, while a few still have two or three branches that travel upward in the retroperitoneal space.
The right side enters the inferior vena cava at an oblique angle and the left side enters the left renal vein at a right angle. As the left spermatic vein has a long stroke, the left side enters the renal vein at a right angle, and after the vein passes through the sigmoid colon, it is compressed by the intestinal tube, plus the vein lacks a venous valve, and there is no muscle pressure around it, so the reflux of the left spermatic vein is blocked, and when standing, a considerable section of the blood column pressure acts downward on the spreading plexus, which makes the varicose vein expand and thicken that is varicocele.
In addition, the sexual function of young and strong people is more vigorous, and the blood supply of scrotal contents is strong, which is the reason why varicocele occurs mostly in young and strong people. In addition, standing for a long time and increasing abdominal pressure are also predisposing factors, for example, soldiers, salesmen, waiters and other occupations are the high incidence occupations.
IV. Clinical manifestations
Usually a small number of patients can be completely asymptomatic, and the main symptom of most patients is a cramping pain in the scrotum after prolonged standing, which can even involve the ipsilateral lower abdomen or inner thighs, and this symptom can be relieved or disappeared after lying down, or some patients come to the clinic only when they find a large number of varicose veins in the scrotum during bathing.
Typical symptoms of varicocele should be: swollen blood vessels like earthworms can be felt or seen in the scrotum, a feeling of swelling or pain in the affected scrotum or testicles, the affected scrotum and testicles are lower than the healthy side when standing, and dilated and tortuous veins can be seen on the surface of the scrotum. The symptoms are more obvious when standing for a long time or when the abdomen is strained, and the symptoms can be reduced or disappeared when lying down.
Of course, there are also some patients with varicocele who come to the hospital because of oligospermia, sperm inactivity, deformed sperm or different combinations of these manifestations, in short, they come to the hospital with decreased semen indicators and impaired fertility, and are found to have varicocele only after examination by physicians.
V. Diagnosis
The diagnosis of varicocele is relatively easy. Careful palpation of the trapezius plexus in the standing position is an important diagnostic method, and the blood filling of the trapezius plexus can be increased when doing breath-holding and abdominal puffing. The degree of varicocele can be classified into 3 levels based on palpation.
Grade 1 (mild): the varicose trapezius plexus can only be palpated during pectus excavatum.
Grade 2 (moderate): the varicose vein mass can be clearly palpated.
Grade 3 (severe): thickened varicose veins can be clearly seen.
The diagnosis of 3rd degree varicocele is easier, while the diagnosis of milder varicocele depends on the experience of the examiner. Moreover, when the diagnosis is difficult to confirm due to previous surgery or combined hydrocele or testicular location in the upper scrotum, ultrasonography is used as a means of confirming the diagnosis in these cases. In recent years, with the rapid development of ultrasound technology, high-frequency probe and color Doppler technology have become increasingly mature, and ultrasound examination of spermatic veins has become intuitive, accurate and easy.
At present, most of the clinical use of color Doppler ultrasound, the examination of the subject to take the supine position, fully exposed vulva, the penis rest on the abdomen, sling cloth towel to hold the scrotum, observe the direction of the varicose veins, internal echogenicity. The maximum internal diameter of the dilated vein is measured with calm breathing and Valsalva breathing as standard images, and CDFI is used to determine the presence or absence of reflux.
The generally accepted ultrasound diagnostic criteria for varicocele are.
1, maximum internal diameter of the spermatic vein ≥1.8ram during calm breathing and ≥2.0mm during valsava test;
2, valsava test is positive, that is, color Doppler detects reflux signal and the duration of T>1 second. The diagnosis of varicocele was made if the above criteria were met simultaneously. It is because of the non-invasive, simple and good repeatability of color Doppler ultrasound that it has a greater diagnostic value for varicocele, and it has become the first choice of examination.
VI. Treatment
Mild varicocele patients can be treated with scrotal support, cold compresses or medications such as mazeline. There are 2 main indications for surgical correction of varicocele: pain and infertility.
Varicocele pain occurs in 2% to 10% of patients and is localized as dull, throbbing, sharp or pulling pain, which is aggravated by exertion or exercise, usually followed by palliative care for 4-8 weeks, including elevation of the scrotum and restriction of exercise. However, most patients fail to achieve sustained effectiveness, and surgery is unavoidable. The literature reports that surgery for pain relief accounts for 48%-61% of all patients undergoing varicocele surgery, with postoperative pain relief success rates of 79%-89%.
Infertility is another major indication for varicocele surgery, with approximately 40% of infertile men having varicocele and approximately 67% of these having improved sperm parameters after varicocele correction, while 1/3 of patients do not respond to surgery, perhaps because of the possible multifactorial nature of low sperm quality, or perhaps because of the actual presence of bilateral varicocele while only unilateral varicocele is detected and corrected clinically.
Regardless, surgical treatment is the primary treatment for patients with severe varicocele or with already declining semen quality. The traditional surgical methods include retroperitoneal cluster ligation of the spermatic vessels, transinguinal high ligation of the internal spermatic veins and laparoscopic high ligation of the spermatic vessels.
In recent years, microsurgical varicocele ligation has emerged internationally, which is a microsurgical approach to ligate the varicocele via the subinguinal route. All veins that may cause varicocele, including the internal scrotal veins and the epididymal veins, are ligated to achieve optimal results with minimal complications.
The incidence of postoperative scrotal effusion after varicocele with microsurgical techniques was 1% compared to 30% with the traditional inguinal route or laparoscopic surgery at 6-month postoperative follow-up. Also, recurrence after varicocele is not uncommon, with an incidence of no more than 1% after microsurgery. In contrast, the incidence of varicocele recurrence after non-microsurgical procedures can reach 15-20%.
Microsurgical varicocele ligation can significantly improve semen quality and pregnancy rate in patients with varicocele infertility; it can also improve semen quality in patients with severe oligozoospermia or non-obstructive azoospermia, which has become the “gold standard” for varicocele treatment. Unfortunately, due to the lack of highly trained urological microsurgeons in China, this procedure is currently only available in a few medical centers or hospitals.