Varicocele is an abnormal dilatation, elongation and tortuosity of the trabecular plexus in the spermatic cord. The prevalence of the disease is about 20% in the general male population and about 40% in infertile men. The disease is more common in young adult males and less common in adolescents, with an overall prevalence of 10.76% in adolescents aged 6-19 years, but the degree of varicocele is more severe, mostly grade III.
Disease Profile
The incidence of varicocele is about 20% in the general male population and about 40% in infertile men. The disease is mostly seen in adult males and relatively rarely in adolescents. Domestic literature reports that the total incidence of varicocele in adolescents aged 6 to 19 years is 10.76%.
Varicocele is a vascular lesion, mostly seen on the left side, accounting for 85% to 90%, and 10% bilaterally, with the right side more often seen in bilateral lesions, and rarely occurring on the right side alone. Varicocele is the first cause of male infertility, accounting for 35% of patients with primary infertility and 50%-80% of patients with secondary infertility.
Disease classification by etiology
Primary type
Secondary type (caused by tumor compression)
Classification by age
Mature type: age 19 years (or older)
Adolescent type: age between 10 and 18 years old.
Grading by physical examination
Subclinical: the varicose veins cannot be detected by palpation or by the patient holding the breath to increase the abdominal pressure (Valsalva test), but minor varicose veins can be detected by color Doppler examination.
Type I: The varicose vein is not obvious on palpation, but can be palpated when the patient holds the breath and increases the abdominal pressure (Valsalva test). The intravenous spermatozoan angiogram shows up to 5 cm of intravenous reflux of the contrast medium.
Grade II: The varicose veins can be palpated.
Grade III: Scrotal enlargement, visible to the naked eye as a mass of varicose veins on the surface of the scrotum.
Causes and pathogenesisPathogenesis
The left internal spermatic vein has a long stroke and may be compressed by the sigmoid colon.
The left renal vein may be compressed by the aorta and superior mesenteric artery.
The right common iliac artery may compress the left common iliac vein, causing partial obstruction of the return of the left spermatic vein.
The upright posture of the person affects the venous reflux.
Defective or malfunctioning spermatic vein valves.
Pathogenesis
Varicocele is associated with abnormal semen, decreased testicular volume, decreased testicular perfusion, and testicular spermatogenic dysfunction by the following possible mechanisms.
Hyperthermia. Varicocele can increase testicular temperature, leading to spermatogenesis disorders and resulting in decreased testosterone synthesis by testicular interstitial cells.
High pressure. Elevated spermatic cord venous pressure leads to inadequate testicular perfusion.
Hypoxia. Poor venous blood return due to varicocele can lead to testicular stasis and hypoxia, which increases venous pressure and induces germ cell apoptosis.
Adrenal metabolite reflux. In patients with varicocele, the blood returning from the adrenal glands can reflux along the spermatic veins, which will metabolites secreted by the adrenal glands and kidneys such as steroids, catecholamines, and 5-hydroxytryptamine can affect testicular blood flow and adversely affect the metabolism of the testes.
Other, such as increased reproductive toxins and increased levels of antioxidants.
Clinical manifestations
Varicocele is usually asymptomatic and is most often detected during a routine physical examination, or during a painless worm-like mass in the scrotum during a self-examination, or during a visit for infertility. Some patients may have symptoms such as cramping, vague pain and discomfort, which may be aggravated after prolonged standing or walking and may be relieved or disappear after lying down. It may be combined with varicose veins of the lower limbs and hemorrhoids.
Diagnosis and differential diagnosis
The diagnosis of varicocele can be confirmed by physical examination and ultrasound, but there is uncertainty about its relationship with scrotal discomfort, pain, fertility and androgen, so attention should be paid to the combination of varicocele with other diseases that cause the above symptoms, especially psychological disorders manifested by physical symptoms.
Diagnosis
1.Interrogation: medical history, marriage and childbirth history, surgery history.
2.Physical examination
1) Body shape, lean and long type patients are prone to it.
2) Examination methods and evaluation of varicose veins: ○1 Visual examination: observe whether there are tortuous veins on the scrotal skin; ○2 Examination when standing; ○3 Examination after lying down; examination after breath-holding (Valsalva) action.
3) Size and texture of the testes (optional)
3.Laboratory examination
1) Semen examination: two consecutive semen examinations within 3 months, the test items should include: semen volume, liquefaction time, pH value, sperm density, activity rate, etc.
2) Sex hormone examination (testosterone, follicle stimulating hormone, luteinizing hormone, etc.)
4) Color Doppler ultrasonography
Color Doppler ultrasonography is of great value in the diagnosis of varicocele. The use of scrotal ultrasound can identify more patients with subclinical spermatic varicoceles in infertility.
a) The internal diameter of the spermatic vein during the resting breath test and the internal diameter of the spermatic vein during the Valsalva maneuver.
b) Reflux, duration of reflux at rest and during Valsalva maneuver.
c) Simultaneous examination of testes and epididymis.
Differential diagnosis
The diagnosis of varicocele is basically confirmed by physical examination and ultrasound, but there is uncertainty about its relationship with scrotal discomfort, pain, fertility and androgens, so attention should be paid to the combination of varicocele with other diseases that cause the above symptoms, especially psychological disorders manifested by somatic symptoms.
Treatment of the disease
The treatment of primary varicocele should be differentiated according to the presence or absence of infertility or abnormal semen quality, the presence or absence of clinical symptoms, the degree of varicose veins and the presence or absence of other complications. Treatment methods include surgical and non-surgical treatment, and most of the literature reports that surgical treatment is the main treatment. Surgical methods include traditional open surgery (common routes include retroperitoneal route and transperitoneal sulcus route), microsurgery, laparoscopic surgery and interventional embolization. Non-operative methods include pharmacological treatment, psychological intervention, scrotal support, hypothermia, dietary modification, etc. They should be selected according to the patient’s specific condition and the actual condition of the local medical institution and the doctor’s mastery of technology, and if necessary, a combination of methods can be chosen. Secondary varicocele should be actively sought and treated for the primary disease.
Drug treatment
(a) Drugs that have effect on varicocele vessels
1.Bioflavonoids: It has been shown that these drugs can reduce the inner diameter of the blood vessels of subclinical varicocele, reduce the development of subclinical varicocele into symptomatic varicocele, and improve the symptoms of perineal pain caused by varicocele to a certain extent, but cannot stop the testicular growth arrest that has already started.
2, heptaosaponin, can reduce capillary permeability, eliminate tissue swelling and edema, can also protect the collagen fibers of the venous wall, gradually restore the elasticity and contraction function of the diseased venous wall, improve the tension and strength of the wall, also can directly act on the intravascular cell receptors, causing venous contraction, increase the venous blood return velocity, reduce venous pressure, thus improving the varicocele caused by symptoms caused by varicocele.
(2) Auxiliary drugs to improve the symptoms
1.Non-steroidal anti-inflammatory drugs.
2. Bioflavonoids.
(3) Auxiliary drugs to improve semen quality
1, carnitine: L-carnitine or acetyl L-carnitine.
2, antioxidant drugs: such as vitamin E, can protect the lipid peroxidation of sperm membrane by scavenging oxygen free radicals and treating weak spermatozoa and sperm dysfunction.
3, estrogen receptor antagonists: such as clomiphene and tamoxifen, which can competitively increase GnRH secretion in vivo and indirectly stimulate FSH and LH secretion, which in turn act on interstitial cells, supporting cells, and spermatogenic cells of the testis to regulate and promote spermatogenic function [97-98].
4. nonsteroidal anti-inflammatory drugs, such as anti-inflammatory pain, ibuprofen, cinnoxicam, etc. Some studies have shown that these drugs can alleviate the symptoms caused by varicocele to a certain extent and can improve the quality of their semen for some patients.
5.Human chorionic gonadotropin.
6. Botanicals and herbal medicines can improve semen quality to a certain extent, but there is a lack of sufficient evidence-based medical evidence in this regard.
Surgical treatment
(a) Indications for surgery.
1. The indications for surgery in adult clinical type patients are recommended as follows.
(1) The following three conditions are present at the same time.
(1) The presence of infertility.
(2) Decreased spermatogenic function of the testes.
(3) Normal fertility of the female partner or possible cure despite infertility.
(2) Those who have no requirement for fertility for the time being, but the examination reveals abnormal semen quality.
(3) If the symptoms associated with varicocele (such as swelling and pain in the perineum or testicles) are more serious and obviously affect the quality of life, and the improvement is not obvious with conservative treatment, surgery can be considered.
(4) If the varicocele is of degree II or III, and the blood testosterone level is obviously decreased, and other diseases are excluded.
For patients with subclinical varicocele, surgery is generally not recommended; however, for patients with clinical varicocele on one side and subclinical varicocele on the other side, bilateral surgery is recommended when surgery is indicated.
3. Indications for surgery of juvenile varicocele.
(1) Significant reduction of testicular volume on the affected side caused by varicocele (see the section on evaluation of testicular function for details).
(2) Grade II or III varicocele.
(3) Decreased spermatogenic function of the testis.
(4) Those with more severe associated symptoms caused by varicocele.
(ii) Surgical modality.
The significance of varicocele in male infertility, the value of surgical intervention, and the advantages and disadvantages of various intervention modalities are still controversial, even though the views on the treatment of varicocele vary in the relevant guidelines of the European Association of Urology and the American Urological Association, but the technique of spermatic vein repair is still the most common surgical treatment for male infertility. Interventions for varicocele repair include interventional techniques (cis or retrograde) and surgical treatments, which are subdivided into embolization and sclerotherapy approaches, and surgical interventions include traditional transinguinal, retroperitoneal, and subinguinal spermatic ligation, microtechnical inguinal or subinguinal spermatic ligation, and laparoscopic spermatic ligation. It has been suggested that microtechnical spermatic vein ligation is the most desirable treatment modality, and Diegidio P et al. reviewed the relevant literature in English from PubMed from 1995 to 2011 comparing the pregnancy rates and complication rates of different treatment modalities for varicocele and showed that microscopic subinguinal and transinguinal route spermatic vein ligation had the best results (Table). However, there are practically no uniform conclusions recognizing the superiority of the microscopic technique.
Depending on the indication for the procedure, the aim of varicocele repair is to improve semen quality and natural pregnancy and/or to reduce scrotal discomfort, and in some cases to increase testosterone levels, with the most significant complications being edema of the scrotum and its contents, testicular artery damage and testicular atrophy, and persistence or recurrence of varicocele. A safe and effective varicocele repair surgery should meet the following points: ① Maintain the integrity of the vas deferens and its vascular system ② Free and ligate all the internal spermatic veins and, if a transinguinal incision is used, also ligate the external spermatic branches ③ Maintain the integrity of the lymphatic vessels and arteries.
1. Transinguinal route and subinguinal route: These include the traditional open procedure and microscopic techniques. In general, the traditional open and microscopic techniques go hand in hand in the world. The transinguinal subinguinal incision for spermatic vein ligation is considered superior to the transinguinal route because it does not require incision of the external oblique abdominal tendons, is mildly painful, and has a rapid postoperative recovery. The ability to identify testicular arteries, lymphatics, and smaller diameter veins is considered the basis for the superiority of microscopic spermatic ligation over other methods in terms of postoperative complication rates, improvement in semen parameters, and conception rates.
2.Transperitoneal retroperitoneal route: i.e. Palomo procedure, which includes both preserved testicular arteries and a set ligation approach without preserving the arteries. This procedure is more convenient, but the incidence of recurrence and varicocele persistence can be 10% to 15%.
3, laparoscopic internal spermatic vein ligation The laparoscopic technique of internal spermatic vein ligation has achieved good results. It has the advantages of identifying and protecting the testicular artery under magnification and can deal with bilateral lesions at the same time. The recurrence rate of laparoscopic spermatic vein ligation is 2-11%, and postoperative edema occurs in about 5-8%. There have been attempts to apply intraoperative lymphatic tracer to identify and protect the lymphatic vessels, but skeptics believe that this method can impair the spermatogenic function.
4, percutaneous embolization technique: including both paracrine and retrograde techniques, this method is more often used by interventionalists. Embolization can be achieved by gelatin sponges, spring coils and sclerotherapy. Although the recurrence rate is low and no postoperative edema occurs, the postoperative pregnancy rate of percutaneous embolization technique for varicocele is not satisfactory and there are operational failures and higher costs to consider. However, percutaneous spermatic vein embolization is very suitable in the management of recurrent or persistent varicocele that requires definitive anatomy by imaging.
In conclusion, it is prudent to assert the superiority of one treatment over the other in the current study, and the choice of treatment modality should take into full consideration the conditions of the hospital, the expertise and experience of the operator, and the wishes of the patient, etc. The final conclusion is pending the results of a large sample of randomized controlled studies.
(iii) Surgical complications.
The common complications after spermatic vein ligation are mainly postoperative edema, testicular artery injury, and recurrence of varicocele, and the above table more objectively compares the incidence of complications of various different surgical procedures and routes.
Oedema is the most common complication after spermatic vein ligation, with an incidence of 3 to 39%, with an average of 7%, and lymphatic vessel injury or misligation is the main cause of oedema. Theoretically, the embolization technique does not produce edema, and the rate of edema is low with microscopic spermatic vein ligation. Testicular syringomyelia occurs in individual patients after surgery, and some of them can subside on their own after a few months, while the opposite requires surgical treatment.
2. Testicular artery injury Most of the postoperative testicular atrophy occurs due to ligation or injury to testicular artery during surgery, and the overall incidence of testicular atrophy is about 0.2%. Since the testicular blood supply also includes the vas deferens artery and the levator muscle artery, the preservation of the testicular artery remains controversial. However, the American Urological Association clearly recommends the use of a magnification technique during spermatic vein ligation to better protect the testicular artery.
The persistence or recurrence of varicocele after spermatic vein ligation is thought to be due to missed ligation of branches of the internal spermatic vein, the external spermatic vein, and the collecting vein. The recurrence rate after spermatic vein ligation is 0.6 to 45%. Reports vary from author to author and from procedure to procedure. The available studies show that the recurrence rate of microscopic spermatic vein ligation by the subcircular route is low.
4. Other Laparoscopic surgery can lead to serious complications such as pelvic and abdominal organ and vascular injuries.