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VARICOCELE SPERMATIC CORD
Category: Urology
Abstract : Varicocele - Definition Dilatation of the veins of the pampiniform plexus of the spermatic cord. Prevalence Found in 15% of men in the general population and 40% of males presenting with infertility. Bilateral or unilateral (left side affected in 90%). Aetiology Incompetent values in the internal spermatic veins lead to retrograde blood flow, vessel dilatation, and tortuosit
Varicocele - Definition
Dilatation of the veins of the pampiniform plexus of the spermatic cord.
Prevalence
Found in 15% of men in the general population and 40% of males presenting with infertility. Bilateral or unilateral (left side affected in 90%).
Aetiology
Incompetent values in the internal spermatic veins lead to retrograde blood flow, vessel dilatation, and tortuosity of the pampiniform plexus.
The left internal spermatic vein enters the renal vein at right angles, and is under a higher pressure than the right vein, which enters the vena cava obliquely at a lower level. As a consequence, the left side is more likely to develop a varicocele.
Pathophysiology
Testicular venous drainage is via the pampiniform plexus, a meshwork of veins encircling the testicular arteries. This arrangement normally provides a counter-current heat exchange mechanism which cools arterial blood as it reaches the testis. Varicoceles adversely affect this mechanism, resulting in elevated scrotal temperatures and consequent deleterious effects on spermatogenesis (± loss of testicular volume).
Presentation
The majority of varicoceles are asymptomatic, although large varicoceles may cause pain or a heavy feeling in the scrotal area. Examine both lying and standing, and ask patient to perform Valsalva manoeuvre (strain down). A varicocele is identified as a mass of dilated and tortuous veins above the testicle (described as feeling like a bag of worms), which decompress on lying supine. Examine for testicular atrophy.
Investigation
Scrotal Doppler ultrasound scan is diagnostic.
Semen analysis: varicoceles are associated with low or absent sperm counts, reduced sperm motility, and abnormal morphology, either alone or in combination (oligoasthenoteratospermia (OAT) syndrome).
Management
Embolization
Interventional radiological technique where the femoral vein used to access the spermatic vein for venography and embolization (with coils or other sclerosing agents).
Surgical ligation
- Retroperitoneal approach: a muscle-splitting incision is made near the anterior superior iliac spine, and the spermatic vessels are ligated at that level.
- Inguinal approach: the inguinal canal is incised to access the spermatic cord, and the veins are tied off as they exit the internal ring.
- Subinguinal approach: veins are accessed and ligated via a small transverse incision below the external ring.
- Laparoscopic: veins are occluded high in the retroperitoneum.
Surgical complications
Varicocele recurrence; hydrocele formation; testicular infarction and atrophy.
Surgical outcome
95% success rate; 70% of men have improvement of sperm parameters
Hit: 414 times
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