Varicocele

Question 1

Define varicocele.

Answer 1

Abnormal dilation of the internal spermatic veins and pampiniform plexus that drain blood from the testis.

Question 2

How common is varcocele?

Answer 2

Occurs in 15% of adolescent boys and adult men;

90% of cases on left side;

10% are bilateral.

40% of men being evaluated in a male fertility clinic will have a varicocele - but not associated with infertility in most (80%)

Question 3

What is the cause of varicoceles?

Answer 3

Primary causes:

increased hydrostatic pressure in the left pampiniform plexus due to

• right-angle insertion of the vein into the left renal vein (right internal spermatic vein joins IVC at an oblique angle)
• left internal spermatic vein is 8-10cm longer causing increased hydrostatic pressure transmission
• “nutcracker” phenomenon as the left renal vein transverses under the SMA

incompetent valves in the left internal spermatic vein

congenitally absent valves

Rarely caused by retroperitoneal or abdominal compressive mass causing a varicocele which does not diminish in the supine position or an isolated right-sided varicocele.

Question 4

What are the risk factors for varicocele?

Answer 4

Somatometric parameters (tall/low BMI) - reported to be more common in males who are taller and heavier, with lower BMI than age-matched controls

FH

Question 5

Why do you get abnormal gonadotrophin leves, impaired spermatogenesis and histological changes to sperm/infertility in varicocele?

Answer 5

Probably due to thermal damage secondary to impaired countercurrent mechanism which usually keeps intrascrotal temperatures 1-2 degrees lower than normal body temperature.

Question 6

How are varicoceles graded?

Answer 6

Varicoceles may be graded based on their size.

• Grade I (small): varicocele palpable only with Valsalva manoeuvre.
• Grade II (moderate): varicocele palpable without Valsalva manoeuvre.
• Grade III (large): varicocele visible through the scrotal skin.
• Sub-clinical: varicocele detected only by Doppler ultrasound.

Question 7

What % volume loss of seminiferous tubules/germinal cells in testes is usually used as an indication for surgery in varicocele?

Answer 7

Seminiferous tubules and germinal cells make up 98% of testicular volume.

A decrease in volume associated with an ipsilateral varicocele has been used as the primary indication for surgical correction in the adolescent.

Significant volume loss has not been standardised; however, most urologists use volume losses of between 10% and 20% (in relation to the unaffected testis) to guide their decision process

Question 8

What are the signs and symptoms of varicocele?

Answer 8

Asymptomatic and usually present after failed attempts at conception

• Painless mass in left hemiscrotum on standing - grade I/II varicocele may only appear on performing Valsalva maneouvre
• Drainage of mass in supine position (or not)
• “Bag of worms” appearance - pathognomonic, on inspection/palpation of spermatic cord above the testicle
• No transillumination (unlike hydrocele)
• Small testicle - larger varicoceles are associated with higher incidence of testicular growth arrest

Question 9

What investigations should be done for varicoceles?

Answer 9

Physical examination is diagnostic in most cases but ultrasound if there is aby doubt about the diagnosis.

Doppler with ultrasound - useful where scotal examination is difficult due to thick scrotal skin or increased amounts of scrotal tissue or may detect sub-clinical varicoceles

Semen analyses (2-3 times) - variable; reduced sperm count; impaired sperm motility (<50% motile spermatozoa)

Serum FSH(+/- GnRH) and testosterone - helps assess testicular function. Raised FSH if impaired spermatogenesis. Testosterone may be low in impaired steroidogenesis.

DNA fragmentation index (DFI) - increased; commonly used test in evaluation of male infertility

Imaging e.g. CT/MRI pelvis may be done to exclude abdominal, pelvis, retroperitoneal mass

Question 10

What is the management of varicocele?

Answer 10

• Observation +/- semen analysis every 1-2yrs - used for grade I varicocele or symmetrical ones (with less than 20% difference in size)

Surgical: fully eliminates 90%; done if semen analysis deteriorates or >grade I.

• Open surgery
• Laparoscopic surgery
• Percutaneous embolisation

Question 11

What are the complications of varicocele?

Answer 11

Post surgical complications:

• Hydrocele
• Recurrence of varicocele
• Bowel injury
• Bleeding/wound infection
• Testicular atrophy

Question 12

What is the prognosis with varicoceles?

Answer 12

Treatment fully eliminates 90% of varicoceles

Procedure may improve semen parameters

Catch up growth of testes in treated adolescents occurs