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Varicocele

Varicocele can be reliably diagnosed with ultrasound which will show dilation of the vessels of the pampiniform plexus to greater than 2 mm. The patient being studied should undergo a provocative maneuver, such as Valsalva’smaneuver (attempting expiration against a closed airway) or standing up during the exam, both of which are designed to increase intra-abdominal venous pressure and increase the dilatation of the veins. Doppler ultrasound is a technique of measuring the speed at which blood is flowing in a vessel. An ultrasound machine that has a Doppler mode can see blood reverse direction in a varicocele with a Valsalva, increasing the sensitivity of the examination.

Recent studies have shown that varicocele is a bilateral diseaseand the diagnosis of the right side is missed by physical examination and even by ultrasonography. The examination should be performed by ultrasonography — color flow doppler performed by highly experienced sonographer or radiologist that will diagnose varicocele by demonstrating back-flow in the right and in the left spermatic veins.

Varicocele represents an abnormal dilation of the pampiniform plexus (veins around the testis and spermatic cord) of the testis.

Prevalence of varicocele is approximately 15%.

35 to 40% of infertile male reportedly have a palpable varicocele

In men with secondary infertility the prevalence of varicocele rises to as much as 80%

Varicoceles have been linked to male infertility and are the most commonly treated condition in men with infertility.

ETIOLOGY AND PATHOPHYSIOLOGY:

Scrotal hyperthermia likely represents the primary mechanism by which a varicocele affects endocrine function and spermatogenesis, both sensitive to temperature elevation.

A varicocele is associated with bilateral spermatogenic abnormalities and leydig cell dysfunction. The testicular histology in infertile men with varicocele is variable, but most studies report reduced spermatogenesis (hypospermatogenesis). Varicocele causes a progressive decline in fertility.

Testosterone concentration is lower in patient with varicocele, suggesting a progressive adverse effect of varicocele on Leydig cell function.

DIAGNOSIS:

TREATMENT:

Varicocele treatment should be offered to the male partner of a couple attempting to conceive when all of the following criteria are met

  • A varicocele is palapable
  • The male partner has one or more abnormal semen parameters or sperm function test results
  • Couple has documented infertility
  • The female partner has normal fertility or potentially correctable infertility.

Varicocele repair is not indicated in men with normal semen analyses or a subclinical (nonpalpable) varicocele.

Indication of Varicocele treatment in Adolescents:

  • A palpable varicocele with ipsilateral testicular atrophy
  • Scrotal pain or discomfort
  • Scrotal mass

Prophylactic treatment of all adolescent varicocele for prevention of future infertility is not recommended

SURGERY:

Best treatment for varicocele is microsurgical subinguinal approach because:

  • It is associated with higher success rate (disappearance of varicocele)
  • Lower complication rate (varicocel recurrence, hydrocele formation and testicular atrophy)

Optical magnification using surgical microscope is mandatory to avoid injury to the testicular artery and lymphatic vessels. Micro Doppler is helpful in locating arteries.

Other approach is inguinal varicocelectomy with slight inferior success rate and increased complication rate.

TREATMENT OUTCOMES:

  • Microsurgical subinguinal or inguinal techniques have significantly better results in terms of sperm motility improvement, pregnancy rate, recurrence, and complications than the traditional surgical techniques of high ligation or of laparoscopy.
  • Improvement in semen parameters are not age dependent.
  • Repair of larger and/or bilateral varicoceles is associated with a greater improvement in semen parameters than unilateral, small left varicoceles, suggesting a dose dependent detrimental effect of varicoceles on testicular function.
  • Varicocelectomy has also been associated with a return of sperm to the ejaculate of azoospermic and severely oligospermic men
  • Varicocelectomy has a beneficial effect on testicular function and/or male fertility potential.
  • Varicocelectomy has also been associated with an improvement in endocrine function (testosterone level).

Complications:

  • Recurrence
  • Hydrocele formation
  • Testicular atrophy

DECISION MAKING

Varicoceles are the most common abnormality identified in males presenting with infertility and present an interesting challenge to urologists who treat such patients. A cause and effect relationship has been established between varicocele and male infertility. Advances in microsurgical techniques now offer patients the option of repairing their varicocele with greater success and fewer complications.

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