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Surgery.(General 1).Scrotum > 6. Varicocele > Flashcards

6. Varicocele Flashcards

1
Q

Varicocele

A
  • Definition
  • Note
  • Etiology
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2
Q

Definition of Varicocele

A

Elongation, dilatation and tortuosity of the pampiniform plexus of veins or the cremasteric veins, Internal and external spermatic veins

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3
Q

Note on Varicocele

A

The testicular vein has no valves & the pampiniform plexus has few inefficient valves

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4
Q

Etiology of Varicocele

A
  1. Primary Varicocele

2. Secondary Varicocele

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5
Q

Primary Varicocele in Etiology of Varicocele

A
  • INCIDENCE
  • AGE
  • ETIOLOGY
  • SIDE AFFECTED
  • CLINICAL PICTURE
  • COMPLICATIONS
  • INVESTIGATIONS
  • TREATMENT
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6
Q

INCIDENCE of Primary Varicocele in Etiology of Varicocele

A

Its percent in males is about 20%

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7
Q

AGE of Primary Varicocele in Etiology of Varicocele

A

usually affects young adults (15-30 years).

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8
Q

ETIOLOGY of Primary Varicocele in Etiology of Varicocele

A
  • Its exact cause is not known
  • but may be due to congenital weakness of venous walls
  • which may be due to familial weakness of mesenchymal tissue
  • Associated with hernia, varicose veins, and flat feet
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9
Q

SIDE AFFECTED in Primary Varicocele in Etiology of Varicocele

A

Primary Varicocele almost always affects the left side

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10
Q

Pathogenesis of Left side affection in SIDE AFFECTED in Primary Varicocele in Etiology of Varicocele

A
  1. The right angled termination of the left spermatic vein into the left renal vein, impedes the venous return, in contrast to the oblique termination of the
    right vein into the IVC.
  2. The left renal vein passes anterior to the aorta & posterior to the superior mesenteric artery (nutcracker action).
  3. Ineffective anti-reflux valves at the junction of the testicular vein and renal vein
  4. The lower position of the left testes & the higher position of the left kidney
  5. Compression of the left testicular vein by the heavily loaded pelvic colon
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11
Q

CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele

A
  • Symptoms

* Examination

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12
Q

Symptoms in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele

A
  1. Usually, the condition is asymptomatic.
  2. Dragging pain
  3. The patient may complain of infertility.
  4. Complications may be the 1st presentation
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13
Q

Main symptom in Symptoms in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele

A

The condition is asymptomatic.

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14
Q

Dragging pain in Symptoms in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele

A
  • what Increase
  • what Decrease
  • Pathogenesis
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15
Q

what Increase Dragging pain in Symptoms in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele

A
  • prolonged standing

* hot weather

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16
Q

what Decrease Dragging pain in Symptoms in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele

A

relieved by lying down and during sleep

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17
Q

Pathogenesis of Dragging pain in Symptoms in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele

A

Due to over relaxation of cremasteric and dartos muscles to inc. heat loss as the venous congestion inc. temp

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18
Q

Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele

A
  • INSPECTION
  • PALPATION
  • Examine the abdomen to exclude 2ry varicocele.
  • GRADING OF VARICOCELE
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19
Q

INSPECTION in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele

A
  1. Large varicoceles are also visible.

2. The affected side of the scrotum hangs lower than normal.

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20
Q

PALPATION in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele

A
  1. Scrotal neck test
  2. A bag of worms
  3. Differentiate between 1ry and 2ry varicocele
  4. Associated pathology
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21
Q

Scrotal neck test in PALPATION in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele

A
  • Normal Finding

* Abnormal Finding indicating Varicocele

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22
Q

Normal Finding in Scrotal neck test in PALPATION in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele

A

Normally only the vas is felt

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23
Q

Abnormal Finding indicating Varicocele in Scrotal neck test in PALPATION in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele

A

inguino-scrotal swelling giving a thrill on cough.

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24
Q

A bag of worms in PALPATION in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele

A

On standing there are dilated, elongated & tortuous veins felt above the testis like “a bag of worms”.

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25
Q

Differentiate between 1ry and 2ry varicocele in PALPATION in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele

A
  1. Primary varicocele empties
    * while the patient is lying down and the scrotum is elevated
    * by the bow test
  2. Examine the abdomen to exclude 2ry varicocele.
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26
Q

Associated pathology in PALPATION in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele

A

There is often a small 2ry hydrocele.

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27
Q

GRADING OF VARICOCELE in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele

A
  • Grade 0 Varicocele detected by duplex only.
  • Grade 1 Varicocele detected by straining.
  • Grade 2 Varicocele detected by palpation.
  • Grade 3 Varicocele detected by inspection
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28
Q

COMPLICATIONS of Primary Varicocele in Etiology of Varicocele

A
  1. subfertility
  2. Recurrent attacks of thrombophlebitis
  3. 2ry vaginal hydrocele.
  4. Anxiety neurosis
  5. Testicular atrophy (rare)
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29
Q

Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele

A
  • Incidence
  • Pathology
  • Etiology
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30
Q

Incidence of Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele

A

15%

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31
Q

Pathology of Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele

A

asthenospermia mainly, then oligospermia

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32
Q

Etiology of Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele

A
  1. Thermal theory
  2. Toxic theory
  3. Hypoxic theory
  4. Note
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33
Q

Thermal theory in Etiology of Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele

A

Warmth from venous congestion affects spermatogenesis

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34
Q

Toxic theory in Etiology of Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele

A

Metabolic substances of steroids & catecholamines are toxic and potentially spermatogenic inhibitors reach the left testicular vein at a higher levels.

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35
Q

Hypoxic theory in Etiology of Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele

A

Venous stasis causes hypoxia & lactic acidosis affecting spermatogenesis.

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36
Q

Note on Etiology of Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele

A

Subfertility occurs even if the condition is unilateral

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37
Q

The reason why Subfertility occurs even if the condition is unilateral in Note on Etiology of Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele

A

due to presence of intercommunicating veins between both testicular veins in the abdomen.

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38
Q

Recurrent attacks of thrombophlebitis in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele

A
  • Etiology

* Clinical Picture

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39
Q

Etiology of Recurrent attacks of thrombophlebitis in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele

A

Due to Accumulation of metabolites

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40
Q

Clinical Picture of Recurrent attacks of thrombophlebitis in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele

A

Stitching pain

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41
Q

INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele

A
  1. Semen analysis
  2. Scrotal Duplex scan
  3. Abdominal U/S
42
Q

Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele

A
  • Normal Findings
  • Affected parameters
  • Normal grading of motility as mentioned by WHO
  • Note
43
Q

Normal Findings in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele

A

Count 20 - 150 million /ml

44
Q

Affected parameters in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele

A

Stress triad:

  • Motility )> shaking motility
  • Count
  • increased the abnormal forms
45
Q

Most prominent parameter in Affected parameters in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele

A

Motility )> shaking motility

46
Q

Normal grading of motility as mentioned by WHO in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele

A
  • Grade a ( fast progressive)
  • Grade b ( slowly progressive)
  • Grade c (non-progressive or local motility only)
  • Grade d (immotile)
  • Note
47
Q

Grade a ( fast progressive) in Normal grading of motility as mentioned by WHO in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele

A

sperm are those which swim forward fast in a straight line-like guided missiles.

48
Q

Grade b ( slowly progressive) in Normal grading of motility as mentioned by WHO in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele

A

sperm swim forward, but either in a curved or crooked line.

49
Q

Grade c (non-progressive or local motility only) in Normal grading of motility as mentioned by WHO in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele

A

sperm move their tails only, but do not move forward.

50
Q

Grade d (immotile) in Normal grading of motility as mentioned by WHO in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele

A

sperm do not move at all.

51
Q

Note on Normal grading of motility as mentioned by WHO in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele

A

ln order to give birth, grade (a + b) shoutd be at least 50% as sperms of grade (c & d) are considered poor.

52
Q

Scrotal Duplex scan in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele

A
  • Normal Findings
  • Abnormal Findings
  • Benefits
53
Q

Normal Findings in Scrotal Duplex scan in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele

A

Normal diameter of the Spermatic veins

0.8 - 1.2 mm (1 mm)

54
Q

Abnormal Findings in Scrotal Duplex scan in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele

A
  1. Reversed blood flow in the Spermatic veins

2. Dilated Spermatic veins ( > 1.5 mm)

55
Q

Benefits of Scrotal Duplex scan in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele

A
  1. Detection of subclinical cases of contralateral side
  2. Detection of Which vein is affected ( internal or external spermatic veins)
  3. provides full assessment of the testis
  4. Detects 2ry vaginal hydrocele if present
56
Q

Abdominal U/S in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele

A

For older patients e.g : 40 years old

exclude causes of Secondary Varicocele
e.g. hypernephroma

57
Q

TREATMENT of Primary Varicocele in Etiology of Varicocele

A

l- Conservative treatment

ll- Surgical treatment

58
Q

Conservative treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A
  1. In early cases, the patient is reassured.
  2. For pain, a scrotal support can be used especially in hot weather.
  3. Advise the patient to take frequent cold baths.
  4. Advise the patient to avoid sexual congestion & prolonged standing.
59
Q

Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A
  • Indications
  • Aim
  • Operations & Approaches
60
Q

Indications of Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A
  1. Subfertility: After complete exclusion of all other causes of infertility.
  2. A large painful varicocele )> severe intolerable pain
  3. Before admission to a military college
61
Q

Aim of Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A

Prevention of venous reflux from the left renal vein to the testicular vein is achieved by attacking the venous return of the testis

62
Q

Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A
  1. Retroperitoneal approach
  2. Inguinal approach
  3. Scrotal approach
  4. Recent trends
63
Q

Retroperitoneal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A
  • Alternative name
  • Principle
  • Advantages
  • Disadvantages
64
Q

Alternative name for Retroperitoneal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A

Palomo’s operation

65
Q

Principle of Retroperitoneal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A

Ligation and division of the testicular vein (1 or 2) in the retroperitoneal space as it emerges from the internal ring

66
Q

Advantages of Retroperitoneal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A

No postoperative hydrocele

67
Q

Disadvantages of Retroperitoneal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A

Recurrence is common as the cremasteric vein is not ligated

68
Q

Inguinal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A
  • Principle
  • Advantages
  • Disadvantages
69
Q

Principle of Inguinal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A
  1. Ligation and division of the pampiniform plexus of veins together with the cremasteric vein in the inguinal canal
  2. Excision of a segment of the vein to a avoid recanalization.
  3. Eversion of the tunica vaginalis is better done routinely
70
Q

Advantages of Inguinal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A

Less incidence of recurrence as the cremasteric vein is ligated.

71
Q

Disadvantages of Inguinal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A

Postoperative hydrocele is common

72
Q

The reason why Postoperative hydrocele is common in Disadvantages of Inguinal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A

due to interruption of the lymphatic vessels so eversion of the tunica vaginalis is better done routinely

73
Q

Scrotal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A
  • Indication
  • Principle
  • Advantages
  • Disadvantages
74
Q

Indication of Scrotal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A
  • Not recommended by all surgeons

* Suitable for neurotic illiterate patients

75
Q

Principle of Scrotal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A
  1. Ligation and division of the pampiniform plexus in the scrotum
  2. Eversion of the tunica vaginalis is recommended routinely by some surgeons.
76
Q

Advantages of Scrotal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A
  • Removal of the swelling & elevation of the testis

* No recurrence as the cremasteric vein is ligated

77
Q

Disadvantages of Scrotal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A
  • Here the testicular artery is an end artery with higher possibility of injury.
  • Postoperative hydrocele is common
78
Q

The reason why Postoperative hydrocele is common in Disadvantages of Scrotal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A

due to interruption of the lymphatic vessels so eversion of the tunica vaginalis is recommended routinely by some surgeons.

79
Q

Recent trends in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A
  1. Laparoscopic varicocelectomy .
  2. Testicular vein embolisation under radiological imaging.
  3. Sub-inguinal microsurgical varicocelectomy
80
Q

Sub-inguinal microsurgical varicocelectomy in Recent trends in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A
  • Alternative name
  • Principle
  • Advantages
  • Note on postoperative outcome
81
Q

Alternative name for Sub-inguinal microsurgical varicocelectomy in Recent trends in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A

Marc Goldstein

82
Q

Principle of Sub-inguinal microsurgical varicocelectomy in Recent trends in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A
  1. The varicocele is ligated at the neck of the scrotum just below the external ring.
  2. This procedure employs a powerful operating microscope that provides 10.25 power magnification to the tiny 1 millimeter testicular artery.
83
Q

Advantages of Sub-inguinal microsurgical varicocelectomy in Recent trends in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A
  1. Reliable identification and preservation of the testicular artery and lymphatic channels.
  2. Reliable identification & Ligation of pampiniform plexus of veins & and cremasteric veins.
84
Q

Note on postoperative outcome in Sub-inguinal microsurgical varicocelectomy in Recent trends in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele

A

Postoperatively, venous return is via the vasal veins, which drain into the internal pudendal system and usually have competent valves

85
Q

Secondary Varicocele in Etiology of Varicocele

A
  • INCIDENCE
  • ETIOLOGY
  • CLINICAL FEATURES
  • TREATMENT
86
Q

INCIDENCE of Secondary Varicocele in Etiology of Varicocele

A

This is a rare condition

87
Q

ETIOLOGY of Secondary Varicocele in Etiology of Varicocele

A

due to obstruction of the venous flow in the
spermatic vein by :

  1. Iatrogenic cause
  2. Hypernephroma
  3. Abdominal or pelvic tumour.
  4. Retroperitoneal fibrosis.
88
Q

Iatrogenic cause in ETIOLOGY of Secondary Varicocele in Etiology of Varicocele

A
  • actually the most common cause

* During hernia surgery During narrowing of internal ring

89
Q

Hypernephroma in ETIOLOGY of Secondary Varicocele in Etiology of Varicocele

A
  • as the malignant cells form a malignant thrombus inside the renal vein
    i. e. permeation of the renal vein
90
Q

CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele

A

Difference between primary varicocele and Secondary varicocele

91
Q

Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele

A
  1. Age
  2. Side
  3. Course
  4. Effect of Lying down or scrotum elevation
  5. Abdominal Examination and U/S
  6. Abdominal
92
Q

Age of primary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele

A

usually affects young adults (15-30 years).

93
Q

Age of Secondary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele

A

It occurs after the age of 40 years.

94
Q

Side of primary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele

A

almost always affects the left side

95
Q

Side of Secondary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele

A

It affects both sides equally

96
Q

Course of primary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele

A

Prolonged course

97
Q

Course of Secondary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele

A

It develops rapidly and enlarges in a few weeks

98
Q

Effect of Lying down or scrotum elevation of primary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele

A

It disappears on lying down or when the scrotum is elevated

99
Q

Effect of Lying down or scrotum elevation of Secondary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele

A

It does not disappear on lying down or when the scrotum is elevated

100
Q

Abdominal Examination and U/S of primary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele

A

No abnormality detected

101
Q

Abdominal Examination and U/S of Secondary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele

A
  1. Hypernephroma
  2. Abdominal or pelvic tumour.
  3. Retroperitoneal fibrosis.
102
Q

Treatment of Secondary Varicocele in Etiology of Varicocele

A

Treatment of the cause

Surgery.(General 1).Scrotum (8 decks)

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