Varicocele: Symptoms and Treatment
- Historical reference
- Varicocele species (classification)
- The causes of varicocele
- Symptoms of varicocele
- Conservative treatment varicocele
- Surgical treatment varicocele
- Postoperative complications
- Prevention of varicocele
Varicocele is a varicose veins of the spermatic cord. It is observed mainly in men aged 17 to 30 years, but it can also occur at an earlier age: in 10 years 6% of boys are found, and in adolescence they suffer up to 16%.
The most common on the left (up to 50-90%), bilateral varicocele up to 17 years is observed in 10%, over 17 - in 48% of cases, and the unilateral expansion of veins on the right is about 2%. This feature is explained by the fact that it is to the left that the spermatic vein is directed to the renal vein almost perpendicularly. Right-sided varicoceles most often develop due to the appearance of a tumor or any other voluminous formation that breaks the venous outflow from the testicle.
In general, varicocele has been known since ancient times: for example, Hippocrates described it as "a cluster of black and yellow, dense blood."
Gradually in the medical world comes the understanding that without proper treatment varicocele can lead to infertility, which makes it urgent to find the most effective means of treatment.
In ancient times, as a treatment, the spermatic veins were pressed directly through the scrotum skin with forceps, cauterized by a red-hot iron or a patient was castrated. Currently, about 120 types of the most popular techniques for surgical intervention with varicocele are known. Also at the initial stages of the disease conservative treatment is widely practiced.
Varicocele species (classification)
Although there are many classifications varicocele, we will focus on the most common.
Primary and secondary
Varicose veins of the cord may arise by itself (be primary, idiopathic) or be the result of any other diseases (secondary varicocele).
Primary varicocele usually occurs until a certain point is almost asymptomatic, but in most cases it is the main cause of male infertility in the world.
Degrees varicocele by Lopatkin
This classification was proposed in 1978 and is used by many urologists to this day, since it is simple enough and easy to understand:
- I degree - varicose is detected only by feeling the spermatic cord (palpation) while straining the patient in a standing position.
- II degree - varicose is visible, however the size and consistency of the testicle does not change.
- III degree - a decrease in the testicle is observed, the veins of the clustelliform plexus are considerably expanded, the consistency of the testicle is changed.
Classification of varicocele in view of circulatory disorders
In 1980, Coolsaet proposed to classify varicocele in view of circulatory disorders in the venous system of the testicle (hemodynamics):
- 1 type - the injection of blood into the testicle occurs from the renal vein.
- 2 type - the blood in the testic vein is thrown from the iliac.
- 3 type - a combination of types №1 and №2.
Classification of varicocele according to WHO
I degree - varicose is not visible, the veins are not palpated in the usual state, but are determined during straining.
II degree - the dilated veins are not visible, however they are well palpated.
III degree - the veins are enlarged, their plexuses are easily palpated and well visible through the scrotum.
Classification of varicocele by symptoms
Taking into account clinical symptoms, the varicocele is distinguished:
2. With the following symptoms:
- Disorders of spermatogenesis,
- Relapse varicocele,
- Various complications.
The causes of varicocele
Although varicocele is known since ancient times, the exact causes of its occurrence, specialists and now call it difficult. With the development of science and the emergence of new opportunities for non-invasive methods of research, new data have been obtained that allow for a more in-depth understanding of certain points in the development of varicocele, but in general the question remains open.
Many modern researchers among the main predisposing factors and causes of varicocele development have noted increased pressure in the veins of the spermatic cord due to:
- Compression of the veins of the cord with a hernial sac, a tumor overflowing with colic masses of the rectum (with chronic constipation);
- Increased intra-abdominal pressure in chronic diarrhea, prolonged tension in the abdominal muscles (in this case, outflow into the lower vena cava is obstructed, and stagnant phenomena are formed);
- Displacement down the left testicle in combination with an inadequate cremaster function;
- Long riding a bicycle, riding a horse;
- Long stay in standing position;
- Scrotal injury;
- Partial compression of the renal vein of the aorta and the superior mesenteric artery (the so-called "tweezers");
- Infringement of the renal vein on the left by its additional trunk;
- Other mechanical factors.
The most significant predisposing factors in the development of varicocele are the following:
- The right angle of fusion of the testicle and renal veins on the left;
- Insufficiency of valves or their absence in the left testicular vein;
- A longer size of the testicle vein on the left than on the right.
The development of varicocele is facilitated by:
- Congenital weakness of the vascular wall,
- Presence of varicose veins of the lower extremities,
- Heart valve defects,
- Phenomena of general insufficiency of connective tissue.
A certain role is played by:
- Masturbation with a constant hyperemia of the male genital organs,
- Vegetative disorders,
- Gonorrhea ,
- Other venereal diseases,
- Condition and disease, which lead to a decrease in testosterone levels.
Symptoms of varicocele
For a long time the varicocele can be completely asymptomatic, developing slowly and slowly. In this case, it is revealed when examined by a urologist for another reason (for example, during a medical examination). As a rule, asymptomatic flow is observed at the initial stages of the disease.
Typical Varicocele Symptoms
The first stage
Although at this stage there are often no complaints, but some patients may be concerned:
- Discomfort in the scrotum,
- Pulling pain in the testicles, groin with strengthening during physical exertion, walking, sexual arousal and disappearance in the supine position.
The second stage
Observed all the symptoms of the first stage, which are more pronounced. They are joined by:
- Increased pain with irradiation down the abdomen with physical activity,
- The appearance of pain in the kidneys,
- Development of neuralgia n. Spermatici,
- Decreased sexual function.
The third stage
The main symptoms intensify, the pains worry even at rest. It is at this stage that infertility often develops.
In adolescents, complaints about scrotal size changes and asymmetry come to the forefront.
Other symptoms varicocele
As a rule, patients complain about:
- Sagging of the scrotum, increasing during walking in the hot season,
- A feeling of heaviness in the groin and scrotum,
- Stupid, pulling, stitching pain or burning sensation of the spermatic cord, giving to the waist, perineum, penis, lower abdomen and thigh.
Since these phenomena increase in standing or walking position, and weaken in the horizontal position or in the event that the scrotum is lifted, many patients lower their hands into the pocket of their trousers and try to keep the scrotum imperceptibly in a raised state, and also prefer melting.
- Sexual weakness,
- Change in the size of the testicles on the side of the lesion
- Itching of the scrotum,
- Urinary incontinence at night,
- Frequent urination.
In severe cases, there may be:
- General weakness,
- loss of appetite,
- weight loss,
- Characteristic changes in spermogram,
- The phenomenon of depression.
During the conversation, the doctor clarifies complaints, the history of the disease, performs a urological examination and, if necessary, prescribes an additional examination.
Complaints and the history of the disease
- Presence / absence of pain, discomfort or heaviness in the scrotum.
- Is there an increase in pain during prolonged standing, walking, intense physical exertion, sexual arousal and their weakening at rest or when raising the scrotum.
- With regular sexual life: the duration of the partner's absence of pregnancy without adequate protection.
- The age of existence of varicocele.
- Postponed diseases: urethritis, prostatitis, STI, parotitis, perineal and scrotum injuries, surgery, etc.
- Presence of chronic intoxications.
- Features of sexual development and sexual life (the beginning of sexual life, the age of the first pollutions, sexual excesses, the time of appearance of pubic hair, the growth of a beard, changes in voice, especially the first year of living together with a partner, etc.).
- Occupational hazards and the presence of factors provoking or predisposing to the development of varicocele: for example, radioactive radiation, contact with carbon disulfide, insecticides, exposure to microwave.
According to various authors, the development of varicocele in many cases was preceded by gonorrhea, mechanical trauma (sports, production or transport), overcooling or overheating.
Symptoms detected during medical examination
1. Expansion of veins in a standing position, as well as during straining. Currently, for this purpose, a modified Valsava sample is used: the patient is asked to breathe and strain. The enlarged veins are defined palpably or visible to the naked eye.
2. With palpation: the presence of small densified segments of obliterated veins, change in the size of the testicle, depending on the stage.
3. Positive test Segond: the patient in the supine position is squeezed into the groin outer ring, and then asked to rise - with varicocele, the veins are filled again.
Also, the doctor can identify the signs of some other diseases that led to the emergence or concomitant varicocele: for example, inguinal hernia, tumors.
Laboratory and instrumental methods of diagnosis
1. Ultrasound of the testis. It is the most informative method for determining its size and revealing various pathologies of this organ. Most often this study is performed in combination with a Doppler attachment, which allows visualizing the scrotal vessels and revealing the reverse casting of venous blood (the so-called reflux), an increase in the diameter of the veins during the Valsava test, and their pronounced tortuosity.
2. Phlebography of the seminiferous veins . With the help of this type of study, it is possible to distinguish the primary varicocele from the symptomatic, but at present it is practically not used (as a rule, sonography is sufficient).
3. Spermogram . If in the initial stages of varicocele it does not practically differ from the norm, the following changes can subsequently be observed:
- Decrease in the number of active spermatozoa,
- Reduction in the number or complete absence of sperm in the sperm,
- No sperm,
- Presence of a lot of dead sperm.
4. Calculation of fertility rate Farris, which should normally be more than 200. To do this, the ejaculate volume is multiplied by the number of spermatozoa (million / ml) and by the percentage of mobile spermatozoa.
5. Study of the level of sex hormones: testosterone, FGS, prolactin, estradiol, luteinizing hormone. Used in the case of differential diagnosis of male infertility in varicocele.
6. Urography. Helps to identify co-occurring diseases: kidney failure, hydronephrosis, anomalies in the structure of the urinary system.
7. Dynamic nephroscintigraphy or indirect isotope angiography , testicular scintigraphy. These radioisotope studies help to study the functional state of the kidneys, the testicle prior to and after surgery, as well as hemodynamics in the vessels of the groinlike plexus.
Conservative treatment varicocele
More is of historical interest, since in most cases it turns out to be ineffective. Nevertheless, urologists in the initial degree of the disease and with asymptomatic flow can appoint:
- Exception of physical activity of a certain type: prolonged walking, lifting weights, dancing, riding, cycling.
- Prevention of increased intra-abdominal pressure: fighting with constipation, flatulence.
- The appointment of venotonicks, vasoconstrictor drugs.
- Regulation of sexual function.
- Regular dousing of the scrotum with cold water to enhance the creammanship function.
- Wearing a special suspension (many patients do not withstand this because of discomfort).
- Toning physiotherapy.
- Refusal of alcohol.
- Systematic swimming, including in open water, winter sports.
Surgical treatment varicocele
To date, it is the surgical methods of varicocele treatment that are most effective.
Indications and contraindications
Indications for surgical intervention:
- In the early stages of varicocele in the absence of efficacy of conservative treatment.
- Regardless of the stage of the disease: the presence of permanent pain.
- Changes in the density and structure of the testicle.
- Reduction of sexual function.
- Changes in the spermogram.
- Restriction of work capacity due to varicocele.
- The widening of the veins, which serves as a contraindication for the army service.
- When the varicocele is strongly affected by the patient's psyche.
They are relatively relative, since they can vary depending on the specific method of surgical intervention. Often contraindications to surgery are the following:
- Asymptomatic course on the first degree of the disease;
- Secondary varicocele due to neoplasms or inflammatory processes of other organs;
- General severe condition of the body.
Surgery of the modern stage
The main goal of any surgical intervention in varicocele is the intersection of the enlarged veins that go to the groin-like plexus and participate in the reverse transfer of blood.
Today, there are four main types of operations with varicocele:
- Bandaging and subsequent excision of the testicle vessels: the operations of Ivanissevich, Kondakova, Palomo, Bernardi, as well as retroperitoneoscopic and laparoscopic techniques.
- X-ray-endovascular: embolization, sclerotherapy, endovascular coagulation.
- Imposition of various vascular anastomoses: proximal testiculoiliacal, spermatikoepigastral, testiculosaphenic.
- Microsurgical methods using optical techniques and performed from access in the groin area.
During this operation, the arteries and veins are exposed, and then bandaged and crossed. Modification - the preservation of patency of lymph vessels, which significantly reduces the likelihood of postoperative complications: epididymitis, hydrocele and edema of the scrotum.
Operations Ivanissevich and Bernardi
Operation Ivanissevich is a classic of traditional surgery, used in children's and adult practice. Its essence is a dressing in the retroperitoneal department of the testicle vein. The frequency of relapse in adults is about 25%, and in children's practice - up to 40%. Bernardi's surgery is performed in almost the same way, however, with a ligation of the testicular artery and somewhat lower (typical complications are testicular atrophy, hydrocele).
Endovascular occlusion of the testicular veins
First, the femoral vein is punctured on the right, a flexible metal conductor is inserted into it, and a catheter is inserted into it, directing the latter to the lower hollow, and then the left adrenal vein. Further selective phlebography and subsequent occlusion of the vessel below the separation of collaterals going to the spine, kidneys and into the retroperitoneal space are performed. Then, as a control, X-ray with contrast medium is again rendered.
Depending on the type of agent used to block the lumen of the vein, distinguish:
- Mechanical embolization with spirals of Gianturco-Andersen-Wallas, silicone balloon, Ivalon seal, cyanocrylates, metallic occluders.
- Transfemoral retrograde sclerosing therapy with a sclerosing agent (eg, thrombovar, varicocide, ethoxiclerol, hypertonic glucose solution with monoethanolamide).
- Combined embolization - balloon or occlusion with spirals with sclerotherapy.
- Occlusion using physical solutions.
- Electrocoagulation with a monopolar electrode.
- Introduction of hot contrast.
Sclerosis and embolization of veins are often accompanied by a relatively frequent occurrence of recurrence varicocele (up to 20%).
There are operations concerning the formation of anastomoses:
- The testicle-iliac.
The essence of these surgical interventions amounts to the fact that a new vessel is actually being created to normalize blood circulation, and varicose dilated ones are bandaged. Virtually all of these techniques imply the presence of a special surgical microscope, through which the surgeon superimposes a vascular suture.
These techniques are used as an alternative to conventional classical methods of operations with varicocele. In this case, the clips are placed on the seed vein or it is bandaged. Laparoscopic coagulation can also be used.
- Acute purulent diseases,
- Presence of previous laparoscopies (depending on the circumstances).
- Pain in the scrotum,
- Impaired spermatogenesis.
As a rule, complications are relatively rare. Specific complications associated with embolization or dressing of the spermatic vein are very rare in the case of laparoscopic and microsurgical techniques.
Lymphostasis of scrotum
This is an early complication after surgery, when the left half of the scrotum begins to swell. In most cases, it gradually disappears and occurs in many operated patients for varicocele. Prevention of lymphostasis is facilitated by wearing during the first 5 days after surgery a special suspension that supports the scrotum.
Atrophy or testicular malnutrition
Atrophy is the most formidable complication of this operation and can be observed after some types of sclerotherapy and classical operations. It is rare enough, however, such operations can not be used in children and young people, since such a complication can become a tragedy for the young man for the rest of his life.
Renewal of pain syndrome
Dull, persistent, aching pain after surgery for a long time disturb about 5% of patients. In part, they are caused by latent lymphostasis, the absence of an enlarged groinlike plexus, which played the role of an amortization pillow, not timely diagnosed and aggravated after surgical intervention with prostatitis, orchitis, etc. Usually, such pain disappears after taking anti-inflammatory and antibacterial therapy.
Immediately after the operation it is quite rare, but to some extent, fluid retention is observed in more than 50%. However, this is just an extra 2-3 ml, which disappears without a trace 6 or 12 months after the operation.
Recurrence of varicocele
The most frequent recurrences of varicocele occur in adolescents and children due to structural features at this age. In adults, the incidence of recurrence of varicocele is significantly lower.
Complications after endovascular surgical techniques
- Allergy to the imposed contrast.
- Pain syndrome.
- Perforation of blood vessels.
Complications of laparoscopy
Prevention of varicocele
Because there are still discussions about the causes of varicocele, there is no serious prevention of this disease.
Currently, most of the recommendations of specialists are as follows:
- At the age of 19-20 years to pass a mandatory examination with a urologist for possible varicocele.
- Regularly once every six months to conduct an independent examination and palpation of the genitals. In case of any changes, you should see the doctor.
- In the case of the first signs of varicocele, you must give up alcohol, regularly live sexually, avoid sexually transmitted diseases. In addition, it is important to eliminate stagnant phenomena in the small pelvis, to treat prostatitis, orchitis, epididymitis in a timely manner.
- As a preventive measure of infertility - modern operation.