Overview
Dilation, bending and lengthening of the trapezius plexus of the spermatic cord are called varicocele. It occurs in young people, mostly between the ages of 16 and 25, with an incidence of about 15%, 99% on the left side and about 1% bilaterally.
Etiology pathology pathogenesis
(A) Anatomical factors.
The blood of testis and epididymis returns through the spermatic vein, which can be divided into three groups, and they have lateral circulation at the outer ring to traffic with each other.
Posterior group: external spermatic vein → inferior abdominal wall vein → femoral vein → external iliac vein.
Middle group: vas deferens vein → superior vesical vein → internal iliac vein.
Anterior group: internal spermatic veins: the veins of the testes and epididymis mainly return through the trapezius plexus of the spermatic cord, which merges into two to four veins in the inguinal canal and crosses the internal ring to the peritoneum to form one vein, called the internal spermatic vein. On the right side, the internal spermatic vein enters the inferior vena cava obliquely; on the left side, it enters the left renal vein at a right angle. The reasons why varicocele is mostly seen on the left side are.
1, the 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 is easy to backflow.
2, the left internal spermatic vein is located after the sigmoid colon, which is easily compressed by the intestinal feces and affects the blood reflux.
(B) Physiological factors
The sexual function of young and strong people is more vigorous, and the blood supply of scrotal contents is strong. So some varicocele can disappear gradually with age. In addition, standing for a long time and increasing abdominal pressure is also a factor in the development of varicocele.
(C) Other factors: retroperitoneal tumor, renal tumor, hydronephrosis, etc. compressing the veins in the spermatic cord can cause symptomatic or secondary varicocele. The primary ones disappear quickly when lying down, while the secondary ones often do not disappear or disappear very slowly.
Diagnosis
(A) Clinical manifestations.
1, Patients may be completely asymptomatic and only found during physical examination.
The scrotum is enlarged and the scrotum and testicles on the affected side are lower than the healthy side when standing up. The scrotal surface can be seen as dilated and tortuous veins. There are earthworm-like soft masses when touched, and the symptoms can be reduced or disappeared by lying down.
Patients may have symptoms of neurasthenia, such as headache, weakness, hypersensitivity, etc. Some patients have sexual dysfunction. Some patients have sexual dysfunction.
4, varicocele can sometimes affect fertility. 9% of varicocele patients have infertility, and 39% of male infertility is caused by varicocele. Severe cases can cause testicular atrophy. The reason is that the temperature in the scrotum of the affected side increases and reflects to the opposite side, making the spermatogonia degenerate, atrophy and reduce the number of sperm; or because the pentraxin or steroid secreted by the left adrenal gland flows back into the testis through the left internal spermatic vein, causing a decrease in the number of sperm.
(ii) Examination.
For secondary varicocele attention should be paid to the examination of the abdomen and intravenous pyelogram should be done to exclude renal tumors. Clinically, varicocele can be divided into three degrees.
Degree 1 (mild): When standing, no varicose veins can be seen protruding from the scrotal skin, but the varicose veins can be felt in the scrotum, and when lying down the varicose veins disappear quickly.
Degree 2 (moderate): dilated veins can be seen on the scrotum when standing, and more obvious varicose veins can be felt in the scrotum, and the mass gradually disappears when lying down.
Degree 3 (severe): there are obvious thick blood vessels on the surface of scrotum, and there are obvious worm-like dilated veins in the scrotum, and the walls of the veins are thickened and hardened; the mass disappears slowly when lying down.
Treatment
Asymptomatic mild varicocele does not require treatment.
Non-surgical treatment: for more severe varicocele or with neurasthenia, the scrotum can be supported and cold compresses can be applied.
Surgical treatment: For severe varicocele, sperm count below 20 million three times in a row or testicular atrophy; if the varicose vein can disappear when lying down, high level ligation of the internal spermatic vein is feasible. The surgical routes are as follows
1.High ligation of the internal spermatic vein via inguinal canal: the same as the hernia incision, the spermatic cord is revealed, the main trunk of the internal spermatic vein and its branches are identified and ligated. This surgical route is simple and commonly used. The dilated external spermatic vein and the testicular lead vein can be ligated at the same time. If an operating microscope is used during the operation, the result is better, the recurrence rate is low, and the complications are few.
2.Translateral iliac fossa route: an oblique incision is made in the left lower abdomen, the peritoneum is pushed open, and the internal spermatic vein is found behind the peritoneum and in front of the external iliac artery and ligated. The disadvantage is that the traffic branch cannot be treated at the same time.
Recently, a catheter has been inserted through the inferior vena cava and left renal vein to the left internal spermatic vein, and then injected with 5% sodium cod liver oil or gelatin sponge and steel ring to embolize this vein to treat varicocele. The disadvantage is that veins with malformations and collateral circulation are not suitable for embolization, and special equipment is required.
If it is accompanied by neurasthenia, the scrotum can be supported and cold compresses can be applied.
Surgical treatment: In case of severe varicocele, sperm count below 20 million for three consecutive times or testicular atrophy; if the varicose vein disappears when lying down, high level ligation of the internal spermatic vein is feasible. The surgical routes are as follows
1.High ligation of the internal spermatic vein via inguinal canal: the same as the hernia incision, the spermatic cord is revealed, the main trunk of the internal spermatic vein and its branches are identified and ligated. This surgical route is simple and commonly used. The dilated external spermatic vein and the testicular lead vein can be ligated at the same time. If an operating microscope is used during the operation, the result is better, the recurrence rate is low, and the complications are few.
2.Translateral iliac fossa route: an oblique incision is made in the left lower abdomen, the peritoneum is pushed open, and the internal spermatic vein is found behind the peritoneum and in front of the external iliac artery and ligated. The disadvantage is that the traffic branch cannot be treated at the same time.
Recently, a catheter has been inserted through the inferior vena cava and left renal vein to the left internal spermatic vein, and then injected with 5% sodium cod liver oil or gelatin sponge and steel ring to embolize this vein to treat varicocele. The disadvantages are that the vein is malformed, the collateral circulation is not suitable for embolization, and special equipment is required.