Varicocele: Symptoms and Treatment
- History reference
- Types of varicocele (classification)
- Causes of varicocele
- Symptoms of varicocele
- Conservative treatment of varicocele
- Surgical treatment of varicocele
- Postoperative complications
- Prevention of varicocele
Varicocele is a varicose veins of the spermatic cord. It is observed mainly in men aged from 17 to 30 years, however, it can also be observed at an earlier age: in 10 years it is found in 6% of boys, and in adolescence they suffer up to 16%.
It is most often found on the left (up to 50–90%), bilateral varicocele up to 17 years old is observed in 10%, over 17 - in 48% of cases, and unilateral dilatation of the veins on the right is about 2%. This feature is explained by the fact that just to the left, the spermatic vein is directed into the renal vein almost perpendicularly. Right-sided varicocele most often develops as a result of the onset of a tumor or some other volume formation that disrupts the venous outflow from the testicle.
In general, varicocele has been known since ancient times: for example, Hippocrates described it as "a congestion of black alkaline, thick blood."
Gradually, in the medical world comes the understanding that without proper treatment, varicocele can lead to infertility, which makes it urgent to search for the most effective means of treatment.
In ancient times, as a treatment, the spermatic veins were clamped directly through the skin of the scrotum with forceps, a hot iron was burned, or the patient was castrated. Currently, there are about 120 types of the most popular methods of surgical treatment for varicocele. Also, in the initial stages of the disease, conservative treatment is widely practiced.
Types of varicocele (classification)
Although there are many classifications of varicocele, we will focus on the most common.
Primary and secondary
Varicose veins of the cord can occur by itself (be primary, idiopathic) or be the result of any other diseases (secondary varicocele).
Primary varicocele usually proceeds until a certain point is almost asymptomatic, but in most cases it is the main cause of male infertility throughout the world.
Degrees varicocele by Lopatkin
This classification was proposed in 1978 and is still used by many urologists, since it is fairly simple and easy to understand:
- Grade I - varicose veins are detected only with the help of feeling the spermatic cord (palpation) while straining the patient while standing.
- Grade II - varicose veins are visible, but the size and consistency of the testicle do not change.
- Grade III - there is a decrease in the testicle, the veins of the creepiform plexus are greatly expanded, the consistency of the testicle is changed.
Classification of varicocele taking into account circulatory disorders
In 1980, Coolsaet proposed to classify varicocele, taking into account circulatory disorders in the venous system of the testicle (hemodynamics):
- Type 1 - the reflux of blood into the testicular comes from the renal vein.
- Type 2 - the blood in the testicular vein is thrown from the iliac.
- Type 3 - a combination of types №1 and №2.
Varicocele classification according to WHO
Grade I - varicose veins are not visible, veins are not palpable in the normal state, but are determined during straining.
Grade II - dilated veins are not visible, but they are well palpated.
Grade III - the veins are dilated, their plexuses are easily palpable and well visible through the scrotum.
Symptoms of varicocele
Given the clinical symptoms distinguish the course of varicocele:
2. With the following symptoms:
- impaired spermatogenesis,
- recurrent varicocele,
- various complications.
Causes of varicocele
Although varicocele has been known since ancient times, experts still find it difficult to identify the exact reasons for its occurrence. With the development of science and the emergence of new opportunities for non-invasive research methods, new data have been obtained, allowing for a more in-depth understanding of some points in the development of varicocele, but the whole question remains open.
Many modern researchers among the main predisposing factors and the causes of the development of varicocele note the increased pressure in the veins of the spermatic cord due to:
- squeezing of the veins of the cord with a hernial sac, tumor, a rectum overflowing with stool masses (for chronic constipation);
- increased intra-abdominal pressure in chronic diarrhea, prolonged tension of the abdominal muscles (in this case, outflow into the inferior vena cava is hampered, and congestion is formed);
- downward displacement of the left testicle, combined with insufficient cremaster function;
- long cycling, riding a horse;
- long standing position;
- scrotal injuries;
- partial compression of the renal vein by the aorta and superior mesenteric artery (the so-called "tweezers");
- infringement of the renal vein on the left of its additional trunk;
- other mechanical factors.
The most significant predisposing factors in the development of varicocele are the following:
- right angle of fusion of the testicular and renal veins on the left;
- valve insufficiency or lack thereof in the left testicular vein;
- the longer size of the testicular veins on the left than on the right.
Development of varicocele contribute to:
- congenital vascular weakness,
- the presence of varicose veins,
- flat feet,
- heart valve defects
- phenomena of general connective tissue deficiency.
A certain role is played by:
- masturbation with constant hyperemia of the male genital organs,
- vegetative disorders
- other sexually transmitted diseases,
- conditions and diseases that lead to a decrease in testosterone levels.
Symptoms of varicocele
For quite a long time, varicocele can be completely asymptomatic, developing slowly and slowly. In this case, it is detected when examined by a urologist for another reason (for example, during a physical examination). As a rule, asymptomatic during the initial stages of the disease.
Typical symptoms of varicocele
Although at this stage most often there are no complaints, however, some patients may be disturbed:
- discomfort in the scrotum,
- pulling pain in the testicles, groin with increased exertion during exercise, walking, sexual arousal and disappearance in the prone position.
Observed all the symptoms of the first stage, which are more pronounced. They are joined by:
- increased pain with radiating down the abdomen during exercise,
- the appearance of pain in the kidneys,
- development of neuralgia n. spermatici
- decreased sexual function.
The main symptoms are aggravated, the pain is disturbed even at rest. It is at this stage that infertility often develops.
In adolescents, complaints about the size of the scrotum and its asymmetry come to the fore.
Other symptoms of varicocele
As a rule, patients complain about:
- sagging of the scrotum, increasing during walking in the hot season,
- feeling of heaviness in the groin and scrotum,
- dull, pulling, stitching pain or burning of the spermatic cord, extending to the lumbar region, perineum, penis, lower abdomen and thigh.
Since these phenomena are aggravated while standing or walking, and weaken in a horizontal position or in the event that the scrotum is raised, many patients lower their hands into the trouser pocket and try to keep the scrotum imperceptibly upright and also prefer to melt.
- sexual weakness
- resizable testicle on the affected side,
- itchy scrotum,
- incontinence at night,
- frequent urination.
In severe cases may occur:
- general weakness
- loss of appetite,
- weight loss,
- characteristic changes of semen,
- phenomena of depression.
During the conversation, the doctor clarifies the complaints, the history of the disease, conducts a urological examination and, if necessary, appoint an additional examination.
Complaints and history of the disease
- The presence / absence of pain, discomfort or heaviness in the scrotum.
- Whether there is an increase in pain during prolonged standing, walking, intense physical exertion, sexual arousal and their weakening at rest or when lifting the scrotum.
- With regular sex life: the duration of the partner's lack of pregnancy without appropriate protection.
- Prescription of existence varicocele.
- Postponed diseases: urethritis, prostatitis, STIs, parotitis, perineal and scrotal injuries, surgeries, etc.
- The presence of chronic intoxication.
- 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, beard growth, voice changes, features of the first year of living together with a partner, etc.).
- Occupational hazards and the presence of factors that provoke or predispose 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 injury (sports, industrial or transport), hypothermia, or overheating.
Symptoms detected during a medical examination
1. Expansion of veins in the standing position, as well as during straining. Currently, a modified Valsavy sample is used for this purpose: the patient is asked to inhale and strain. Dilated veins are palpable or visible to the naked eye.
2. On palpation: the presence of small compacted areas of obliterated veins, changing the size of the testicle, depending on the stage.
3. Positive Segond test: in the supine position, the outer ring in the groin is pinched and then asked to rise - with varicocele, the veins refill.
Also, the doctor can identify signs of some other diseases that led to or accompanying varicocele: for example, an inguinal hernia, a tumor.
Laboratory and instrumental diagnostic methods
1. Ultrasound of the testicle. It is the most informative method for determining its size and identifying various pathologies of this organ. Most often, this study is performed in conjunction with a Doppler device that allows you to visualize the vessels of the scrotum and detect the return of venous blood (the so-called reflux), an increase in the diameter of the veins during the Valsawa test, and their pronounced tortuosity.
2. Phlebography of the spermatic veins . With this type of research, it is possible to distinguish primary varicocele from 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 practically does not differ from the norm, then the following changes can be observed:
- reducing the number of active sperm,
- a decrease in the number or complete absence of sperm in the semen,
- lack of sperm
- the presence of many dead sperm.
4. The calculation of the fertility rate of Farris, which normally should be more than 200. For this, the volume of ejaculate is multiplied by the number of spermatozoa (million / ml) and the percentage of motile 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 with varicocele.
6. Urography. It helps to identify associated diseases: kidney prolapse, hydronephrosis, anomalies of the urinary system.
7. Dynamic nephroscintigraphy or indirect isotopic angiography , testicular scintigraphy. These radioisotope studies help to study the functional state of the kidneys, testicles before and after surgery, as well as hemodynamics in the vessels of the uviform plexus.
Conservative treatment of varicocele
More of historical interest, as in most cases it turns out to be ineffective. However, urologists in the initial extent of the disease and asymptomatic course may appoint:
- The exclusion of physical activity of a certain type: long walking, lifting weights, dancing, riding, cycling.
- Prevention of increased intra-abdominal pressure: the fight against constipation, flatulence.
- Purpose venotonikov, vasoconstrictor drugs.
- Regulation of sexual function.
- Regular douche of the scrotum with cold water to enhance the cremasteric function.
- Wearing a special suspensor (many patients do not withstand this due to the occurrence of discomfort).
- Toning physiotherapy.
- Refusal of alcohol.
- Systematic swimming, including open water, winter sports activities.
Surgical treatment of varicocele
To date, it is the surgical treatment of varicocele that are the most effective.
Indications and contraindications
Indications for surgery:
- In the early stages of varicocele in the absence of effectiveness of conservative treatment.
- Regardless of the stage of the disease: the presence of persistent pain.
- Changes in the density and structure of the testicle.
- Decreased sexual function.
- Changes on semen.
- Disability due to varicocele.
- An enlarged vein that serves as a contraindication for army service.
- With a strong effect of varicocele on the psyche of the patient.
They are relatively conditional, as they may vary depending on the specific method of surgical intervention. Often, contraindications to surgery are as follows:
- asymptomatic in the first degree of the disease;
- secondary varicocele due to neoplasms or inflammatory processes of other organs;
- general serious condition of the body.
Surgery of the modern stage
The main goal of any surgical intervention for varicocele is the intersection of the enlarged veins heading into the uviform plexus and participating in the re-injection of blood.
Today, there are four main types of operations for varicocele:
- Ligation and subsequent excision of testicular vessels: operations of Ivanissevich, Kondakov, Palomo, Bernardi, as well as retroperitoneoscopic and laparoscopic techniques.
- X-ray endovascular: embolization, sclerotherapy, endovascular coagulation.
- Overlay of various vascular anastomoses: proximal testicular or spermatics, epigastric, testicular and suphalic.
- Microsurgical techniques using optical technology and performed from access in the groin area.
During this operation, the spermatic arteries and veins are exposed, and then they are tied up and intersected. The modification is the preservation of the patency of the lymphatic vessels, which significantly reduces the likelihood of the development of postoperative complications: epididymitis, hydrocele and scrotal edema.
Operations of Ivanissevich and Bernardi
Operation Ivanisevich is a classic of traditional surgery, used in pediatric and adult practice. Its essence is a ligation in the retroperitoneal department of the testicular vein. The recurrence rate in adults is about 25%, and in pediatric practice - up to 40%. The operation of Bernardi is performed in almost the same way, however, with ligation of the testicular artery and slightly 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 through it, directing the latter into the inferior vena cava, and then the left adrenal vein. Next, perform selective phlebography and subsequent occlusion of the vessel below the discharge of collaterals going to the spine, kidneys and in the retroperitoneal space. Then, as a control, an x-ray with a contrast agent is again performed.
Depending on the type of tool used to block the vein lumen, there are:
- Mechanical embolization with Gianturco-Andersen-Wallace spirals, silicone balloon, Ivalon seal, cyanocrylates, metal occludermes.
- Transfemoral retrograde sclerotherapy with a sclerosing agent (for example, thrombovar, varicocide, ethoxysclerol, hypertonic glucose solution with monoethanolamide).
- Combined embolization - balloon or occlusion spirals with sclerotherapy.
- Occlusion using physical solutions.
- Electrocoagulation by a monopolar electrode.
- Introduction of hot contrast.
Hardening and embolization of the veins is often accompanied by a relatively frequent occurrence of recurrence of varicocele (up to 20%).
There are operations for the formation of anastomoses:
The essence of these surgical interventions is that a new vessel is actually created to normalize blood circulation, and varicose dilated - are tied up. Практически все эти техники подразумевают наличие специального хирургического микроскопа, с помощью которого происходит наложение хирургом сосудистого шва.
Данные методики используются в качестве альтернативы обычным классическим методам операций при варикоцеле. В этом случае накладывают клипсы на семенную вену или ее перевязывают. Также может использоваться лапароскопическая коагуляция.
- острые гнойные заболевания,
- наличие предыдущих лапароскопий (в зависимости от обстоятельств).
- боли в мошонке,
- нарушение сперматогенеза.
Как правило, осложнения встречаются сравнительно редко. Специфические осложнения, связанные с эмболизацией или перевязкой семенной вены, наблюдаются очень редко в случае использования лапароскопических и микрохирургических техник.
Это раннее осложнение после операции, когда начинает отекать левая половина мошонки. В большинстве случаев он постепенно исчезает и встречается у многих прооперированных по поводу варикоцеле пациентов. Профилактике лимфостаза способствует ношение в течение первых 5 дней после операции специального суспензория, поддерживающего мошонку.
Атрофия или гипотрофия яичка
Атрофия является самым грозным осложнением данной операции и может наблюдаться после некоторых видов склеротерапии и классических операций. Встречается достаточно редко, однако операции подобного рода не могут использоваться в детском возрасте и у молодых, так как подобное осложнение может стать для молодого человека трагедией на всю оставшуюся жизнь.
Возобновление болевого синдрома
Тупые, постоянные, ноющие боли после операции длительное время беспокоят около 5% больных. Частично они обусловлены скрытым лимфостазом, отсутствием расширенного гроздевидного сплетения, игравшего роль амортизационной подушки, своевременно не диагностированным и обострившимся после хирургического вмешательства простатитом, орхитом и т.п. Обычно такая боль исчезает после приема противовоспалительной и антибактериальной терапии.
Непосредственно после операции встречается достаточно редко, однако в той или иной степени задержка жидкости наблюдается более чем в 50%. Однако это всего лишь лишние 2–3 мл, которые бесследно исчезают спустя 6 или 12 месяцев после операции.
The most common relapses of varicocele are found in adolescents and children due to structural features at a given age. In adults, the frequency of recurrence of varicocele is much lower.
Complications after endovascular surgical techniques
- Allergy to the entered contrast.
- Pain syndrome.
- Perforation of blood vessels.
Complications with laparoscopy
Prevention of varicocele
Due to the fact that there are still discussions about the causes of varicocele, there is no talk about serious prevention of this disease.
Currently, most of the recommendations of experts comes down to the following:
- At the age of 19–20, undergo a mandatory examination by a urologist for possible varicocele.
- Regularly 1 time in six months to carry out self-examination and palpation of the genitals. In the event of any changes need to see a doctor.
- In the case of the first signs of varicocele, it is necessary to abandon alcohol, to regularly have sex, to avoid sexually transmitted diseases. In addition, it is important to eliminate congestion in the pelvis, in a timely manner to treat prostatitis, orchitis, epididymitis.
- As a prophylaxis of infertility, it is modern to operate on.