Varicocele: A common urological condition that results in a series of clinical symptoms due to tortuous dilatation of the trapezius plexus of the testis, varicocele has received widespread attention due to numerous studies showing that varicocele can cause structural and functional damage to testicular tissue and is significantly associated with male infertility.
Epidemiological features
More than 90% of varicocele occurs on the left side, and the overall prevalence of varicocele in the male population is 10-15%, and approximately 30%-50% of men with primary infertility have varicocele. Although varicocele can develop in all age groups, it is most common in adolescent males.
Classification
Primary varicocele: varicocele due to anatomical factors and dysplasia.
Subclinical varicocele: It is a mild varicocele that cannot be detected on physical examination but can be detected by ultrasound, nuclear scan or color Doppler examination. The diagnosis is generally considered to be established by a vein diameter of more than 2 mm.
Secondary varicocele: Intra-abdominal or retroperitoneal tumor, hydronephrosis or ectopic vascular compression of the superior spermatic veins may also lead to unilateral or bilateral varicocele, which is called secondary varicocele.
Clinical manifestations
Most patients are detected during physical examinations without conscious discomfort, or during infertility visits. The pain may radiate to the inguinal region and lower abdomen, and is aggravated by standing and walking, and is relieved by lying down and resting.
Treatment
(I) Non-surgical treatment
For asymptomatic or mild symptoms, non-surgical treatment is recommended, such as scrotal brace, local cold compress and avoiding pelvic and perineal congestion caused by excessive sexual intercourse.
(II) Surgical treatment
Indications for surgery
Surgery should be performed if the symptoms are serious enough to affect daily life and workers or if the symptoms cannot be relieved by non-surgical treatment; those with obvious varicocele or abnormal semen or with infertility should also be considered as indications for surgery.
In the past, it was thought that some patients with mild varicose veins might relieve themselves after sexual maturity, therefore, mild varicose veins without symptoms and without affecting fertility could be left untreated. As the research on subclinical varicocele progresses, it is believed that subclinical varicocele can also affect testicular function, therefore, patients with all types of varicocele should be actively treated. Some even advocate that adolescents should undergo surgery as soon as varicocele is detected to avoid affecting their future fertility.
①If the varicocele is infertile, there are abnormal semen examination, no other diseases affecting fertility are found in medical history and physical examination, normal endocrine examination and no abnormal findings in female fertility examination, regardless of the severity of varicocele, as long as the diagnosis of varicocele is once established, surgery should be performed promptly.
②Severe varicocele with obvious symptoms, such as more standing that is to feel the pain of scrotal swelling, etc., physical examination found testicular obvious shrinkage, even if there has been fertility, the patient has the desire for treatment can also consider surgery.
Clinical observation shows that the incidence of prostatitis and seminal vesiculitis in patients with varicocele increases significantly and is twice as high as normal people, so if the above two diseases exist at the same time and prostatitis is not cured for a long time, varicocele surgery can be chosen.
④For adolescent varicocele, since it often leads to pathological and progressive changes in the testes, it is now advocated that adolescent varicocele with testicular volume reduction should be treated with surgery as early as possible to help prevent infertility in adulthood.
⑤ For patients with mild varicocele, if the semen analysis is normal, they should be followed up regularly (every 1-2 years), and once there is abnormal semen analysis, testicular shrinkage and texture softening, they should be operated promptly.
(6) For patients with varicocele accompanied by oligospermia due to non-obstructive factors, simultaneous testicular biopsy and varicocele surgery is recommended to help perform assisted reproduction.
Contraindications to surgery
A history of abdominal infection and open pelvic surgery with extensive adhesions is a contraindication to high level ligation of the internal spermatic vein.
Surgical methods
The traditional treatment is based on open surgery. The principle of surgery is to cut and ligate the internal spermatic vein at a high level at the level of the retroperitoneal, internal inguinal canal ring. Usually an oblique inguinal incision is used to perform a high level ligation of the internal spermatic vein and to remove part of the dilated vein in the scrotum.
In recent years, laparoscopic high ligation of the internal spermatic vein for varicocele has become more common.
In addition, microscopic high ligation of the spermatic vein and interventional embolization of the spermatic vein are also used clinically with good results.
Prognosis
Timely surgical treatment is of positive significance for the protection of testicular function and the improvement of sperm count and morphology. The semen improvement rate of infertility patients who undergo high level ligation of the internal spermatic vein is about 80%, and the conception rate is 50%. Some studies have concluded that subclinical varicocele is more effective than clinical varicocele and early treatment is more effective than waiting for observation before treatment.