The concept of varicocele
Varicocele in men refers to the abnormal tortuous, elongated and dilated trapezius plexus caused by the obstruction of blood return to the spermatic veins, which forms a worm-like mass in the scrotum. It is a common disease among young adults, accounting for 10-15% of the incidence and 20%-30% of male infertility. Thus, male varicocele is one of the important causes of male infertility. Patients mostly have no obvious symptoms, but a few of them may have soreness and pain in the scrotum, which is aggravated after walking or labor and relieved after lying down.
First of all, let us look at the anatomy of the spermatic veins. The veins of the testes, epididymis and vas deferens converge to form the spermatic veins. These veins, about 10-20 in number, form the trapezoid plexus of the spermatic cord and finally merge into the internal spermatic vein, the external spermatic vein and the vas deferens vein. Varicocele occurs mainly in the internal spermatic vein, which becomes 1-2 branches above the groin and then one vessel upwards. This internal spermatic vein travels a long way up behind the peritoneum. The right spermatic vein enters at an oblique angle directly into the thick lumen of the inferior vena cava, while the left spermatic vein needs to enter the left renal vein at a right angle and then into the inferior vena cava.
Because the left spermatic vein has an extra “transit” and because the sigmoid colon may compress it during its long journey, as well as the aorta and superior mesenteric artery when they turn, most varicose veins occur on the left side. In addition, there are often many valves in the spermatic veins which control the direction of blood flow, that is, they only let blood flow from the scrotum to the heart and do not let blood flow downward back to the scrotum, when these valves are missing or have dysfunction, the return of blood flow to the veins in the spermatic cord is easily blocked and thus varicocele occurs. There are also predisposing factors, such as prolonged standing or walking and excessive sexual activity.
How it causes infertility
Mechanisms of infertility caused by varicocele.
(1) Blood stagnation in varicose veins causes local temperature increase in the testes and affects spermatogenesis.
(2) Blood stagnation affects the blood circulation of the testes, which makes the testes lack the necessary nutrition and oxygen supply, and affects the spermatogenesis of the testes.
(3) Reflux of blood from the internal spermatic vein causes endocrine products of the adrenal glands and kidneys such as steroids and catecholamines to enter the testes with the refluxed venous blood, which affects testicular spermatogenesis.
(4) Varicocele causes pathological changes in the testis, which can lead to primary testicular hypofunction, interstitial edema of testicular tissue with microcirculatory disorders, thickening of the basement membrane of the varicocele, resulting in mid- to late-stage spermatogenic process disorders and hypoxic degeneration of the supporting cells. Support cells are the main material basis of the blood-testis barrier, and damage to the blood-testis barrier triggers an autoimmune response, producing anti-sperm antibodies (AsAb), resulting in immune-mediated damage.
(5) Electron microscopic findings confirm that spermatocytes in patients with varicocele have impaired maturation, abnormal structure, dilated, destroyed or shrunken acrosomes, vacuoles in the spermatozoa head, and reduced acrosome integrity.
Symptoms and diagnosis of varicocele
Symptoms and related clinical manifestations.
1. Enlarged scrotum or testicles, cramping, swelling and pain: swollen blood vessels like earthworms can be felt or seen in the scrotum. The scrotum or testicles on the affected side have a feeling of swelling or pain, the scrotum is swollen, the scrotum and testicles on the affected side 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, but lying down can make the symptoms reduce or disappear. Sitting for a long time will cause the local temperature of the spermatic cord to rise, swelling and pain.
2, the emergence of infertility: many men because of infertility, go to the hospital after examination only to find that they suffer from varicocele, and it is understood that about two-thirds of men suffering from varicocele will occur about two-thirds of semen abnormalities, and lead to infertility. Therefore, if you have infertility, promptly go to the hospital to check whether varicocele.
3.Neurasthenia symptoms: Patients suffering from varicocele can have neurasthenia symptoms, such as headache, weakness, hypersensitivity, etc.
4.Sexual dysfunction: Some patients suffering from varicocele may have low libido, decreased sexual pleasure, painful sex life, erectile dysfunction, premature ejaculation and other sexual dysfunctions.
Diagnosis.
Diagnosis is not difficult; during the examination, the patient is asked to stand. The scrotum on the affected side can be seen to be markedly droopy, with sometimes curved veins on the skin surface. The veins in the scrotum are coiled into a mass, and a male examination may reveal tortuous and dilated spermatic veins like earthworms. On examination, a soft, compressible mass of varicose veins can be palpated in the spermatic cord above the testes. Occasionally, small nodules of thrombosis may be palpated. A mass of the same nature may also be palpated in the lower posterior aspect of the testis. The mass disappears quickly when the patient is lying down. If the mass does not disappear after lying down, it should be considered secondary and appropriate tests should be performed to rule out tumors or other causes of the disease.
Ultrasound, enhanced CT, MRI are good methods to diagnose this disease, but spermatic venography is the most reliable method to diagnose primary varicocele, which can not only understand the existence and degree of varicocele and the presence of anatomical variants, but also decide whether surgery or embolization is appropriate, study the reasons for the continued existence of varicocele after surgery and decide the timing of surgery, etc.
According to the different factors of development, varicocele is generally divided into primary varicocele and secondary varicocele. Primary varicocele mostly occurs at the age of 15-30 years old, which is presumed to be the period of abundant blood supply to the scrotum and its contents, high sexual desire, and excessive sexual stimulation can reflexively cause pelvic and spermatic veins to be congested, thus causing varicocele to occur. In some patients, varicocele can disappear or be reduced after marriage; secondary varicocele is caused by pressure on the spermatic vein on the way of reflux, which mostly occurs above 35 years old, and common compression lesions are: renal tumor, ureteral tumor, retroperitoneal tumor, hydronephrosis, perinephric pus, vagus vessel, iliac vein obstruction, etc.
More than 90% of varicose spermatic veins occur on the left side for two reasons.
1, the left internal spermatic vein is long and enters the renal vein at a right angle, and the blood flow is subject to certain resistance. The left internal spermatic vein near the left renal vein has no valve, so the blood flows backwards easily;
2, the left internal spermatic vein is located after the sigmoid colon, which is easily compressed by feces in the intestine and affects the blood return flow.
Clinically, varicocele is classified into four grades.
Grade III: dilated veins can be seen protruding from the scrotal skin when the patient stands, like a mass of earthworms, which can be easily palpated.
Grade II: The dilated veins are very easily palpable on palpation but cannot be seen.
Grade I: not obvious on palpation, but may be present on Valsalva test.
Grade 0: No symptoms of varicocele are manifested, and Valsalva test cannot be present.
Treatment of varicocele
Asymptomatic mild varicocele does not require treatment. Non-surgical treatment includes scrotal support and cold compresses for mild varicocele or with neurasthenia, and medication such as carnitine complex, clomiphene and herbal medicine. For male infertility patients with more severe clinical symptoms of varicocele, or with sperm abnormalities (sperm count below 20 million for three consecutive times) or with testicular atrophy, surgical treatment is an option.
Surgical treatment includes traditional surgical procedures, laparoscopic surgical treatment and interventional embolization treatment. Traditional surgical methods include transperitoneal retroperitoneal set ligation of spermatic vessels, transinguinal internal spermatic vein high ligation and laparoscopic surgery. The incidence of postoperative complications such as testicular syringomyelia and testicular artery injury and the recurrence rate of varicocele are high. In the last 20 years, with the development of interventional radiology, the application of interventional embolization techniques to treat varicose veins has replaced most surgical treatments. There is extensive traffic between the spermatic veins and the vas deferens and external spermatic veins, as well as a large amount of traffic between the deep and superficial groups of veins, and embolization of the spermatic veins and the tracheal plexus does not interfere with the blood return to the testes and the testicles.
Embolization of the seminiferous veins eliminates the backflow, which is a direct cause of varicocele, and there is little displacement of the embolized material due to the backflow. This is the basis for percutaneous puncture for spermatic vein embolization. With the development of interventional radiology, performing vein embolization has replaced some of the surgical treatments, and it has the advantages of being simple, less painful, and less likely to recur, reducing the recurrence rate compared to traditional surgery.