varicocoele Flashcards
definition of varicocoele
dilated veins of pampiniform plexus due to proximal obstruction of the spermatic vein
aetiology of varicocoele
idiopathic/primary
- not fully understood
- L testicle more
- longer course of L spermatic vein and its insertion at R angle into L renal vein = slower drainage and increased hydrostatic pressure
- L renal vein passes between the aorta and superior mesenteric artery = increase suseptibility of the renal vein to compression (nutcracker phenomenon) = increased intravascular pressure in L spermatic vein = varicocele formation
symptomatic/secondary
- caused by a mass in the retroperitoneal space (ormand disease, lymphoma, renal cell carcinoma) obstructing venous drainage into inferior vena cava (R sided Varicocele) or L renal vein (L varicocele) or a thrombotic event
pampiniform plexus drain into the testicular veins in the abdo
on R testicular vein goes into IVC
on L goes into L renal vein, then IVC
if valves in testicular veins are defective, blood will reflux into the paminiform plexus
persist in supine position because of physical obstruction to blood flow in the spermatic vein
epidemiology of varicocoele
most common cause of scrotal enlargement in men
incidence 20-30% of male population
sx of varicocoele
L side often more affected
visible as distended scrotal bv that feel like a bag of worms
dull ache
painless enlargement
heaviness of affected scrotum
symptoms worse when standing or performing the valsalva manouver
rarely paresthesia
signs of varicocoele
bv feel like a bag of worms
negative translumination (doesnt transluminate)
valsalva maneuver can engorge the veins further
they should disappear in supine position (veins drain)
Ix for varicocoele
US dilated >2mm hypoechoic pampiniform vessels
specificially colour flow doppler (duplex) US - demonstrates enlarged veins and abnormal reflux of blood into them with valsalva maneuver
US of kidney - check for renal cell carcinoma
mx of varicocele in adolescent
reassurance if
* sub clinical or grade 1
observation if
* grade 2 or 3 and less than 20% size difference or symetrical testes
surgery if
* grade 2 or 3 and asymmetrical (>20% or 2cm3 difference)
mx of variocele in adults
reassurance if
* sub clinical or grade 1 with normal semen parameters
observation if
* grade 2 or 3 and asx or normal semen parameters
surgery if
* grade 2 or 3 and sx, or grade 1-3 with abnormal semen parameters
monitoring variocele
adolescents
* annual exam until testicular growth is complete
* after repair - examine at 1mo, 6mo and then 12-18 mo intervals
adults
* with normal semen - observe with semen analysis every 1-2yrs
* if surgery - every 3 mo for 1 yr
improvements in semen parameters at 6-9mo
complications of variocele
post-surgical
* coil migration/extravastion of contrast material
* post-surgical
* hydrocele
* variocele recurrance
* bowel injury
* bleeding/wound infection
* testicular atrophy
