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Varicocele

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Varicocele
Gray1147.png
Cross section showing the pampiniform venus plexus
Pronunciation
Specialty Urology

A varicocele is an abnormal enlargement of the pampiniform venous plexus in the scrotum, this plexus of veins drains blood from the testicles. The testicular blood vessels originate in the abdomen and course down through the inguinal canal as part of the spermatic cord on their way to the testis. Varicoceles occur in around 15% of all men.[3]

Signs and symptoms

Varicocele on the persons left, images right.

The varicoceles might be noticed as soft lumps, usually above the testicle and mostly on the left side of the scrotum.[4] Right-sided and bilateral varicoceles do also occur, some people who have them feel pain or heaviness in their scrotum.[4] Varicoceles are sometimes discovered when investigating the cause of male infertility.[5][6]

Cause

The cause is unknown, but is thought to result from abnormalities of the veins inside the testicles, leading to a backup of blood that cannot flow, which in turn causes swelling.[4][7] There are three main theories as to the anatomical cause; the first has to do with the geometry of the veins, wherein the vein on the left side connects to the larger outflowing vein at a right angle, which tends to fail; the second is that valves that are supposed to prevent backflow fail (venous insufficiency); the third is that pressure in upstream arteries creates a “nutcracker” syndrome.[7]

Pathophysiology

Often the greatest concern with respect to varicocele is its effect on male fertility, the relationship between varicocele and infertility is unclear; some men with the condition are fertile, some have sperm that are normal in shape and move normally, but are compromised in function, and some have sperm with abnormal shapes or that do not move well.[7] Theories as to how variocele affects sperm function include damage via excess heat caused by the blood pooling and oxidative stress on sperm (ROS).[3][7][8][9]

Tobacco smoking and mutations in the gene expressing glutathione S-transferase Mu 1 both put men at risk for infertility; these factors may also exacerbate the risk that varicocele will affect fertility.[7]

Diagnosis

Varicocele in ultrasound (left: testicle)
Varicocele

Following discovery of the sign of swelling comprising a mass, varicocele can be confirmed with ultrasound, which will show dilation of the vessels of the pampiniform plexus to be greater than greater than 2 mm.[10]

Treatment

Sewn up wound after varicocele surgery

The two most common surgical approaches are retroperitoneal (abdominal using laparoscopic surgery), infrainguinal/subinguinal (below the groin) and inguinal (groin using percutaneous embolization).[3] Possible complications of this procedure include hematoma (bleeding into tissues), hydrocele (accumulation of fluid around the affected testicle), infection, or injury to the scrotal tissue or structures. In addition, injury to the artery that supplies the testicle may occur, resulting in a loss of a testicle.[3]

Whether having variocele surgery or embolization improves male fertility is controversial, as good clinical data are lacking.[6] There is tentative evidence that varicoceletomy may improve fertility in those with obvious findings and abnormal sperm;[3] however, this has a number needed to treat of 7 for varicoceletomy and 17 for embolization.[11][12] There are also studies showing that the regular surgery has no significant effect on infertility.[6] A 2012 Cochrane review found tentative but unclear evidence of improved fertility among males treated for varicocele.[13]

Epidemiology

Around 15% of all adult males, up to 35% of men who are evaluated for male infertility, and around 80% of men who are infertile due to some other cause, have varicocele.[3][6]

References

  1. ^ "Varicocele". Merriam-Webster Dictionary. Retrieved 2016-01-21. 
  2. ^ "Varicocele". Oxford Dictionaries. Oxford University Press. Retrieved 2016-01-21. 
  3. ^ a b c d e f Kupis, Ł; Dobroński, PA; Radziszewski, P (2015). "Varicocele as a source of male infertility - current treatment techniques". Central European journal of urology. 68 (3): 365–70. doi:10.5173/ceju.2015.642. PMC 4643713Freely accessible. PMID 26568883. 
  4. ^ a b c "Testicular lumps and swellings - Causes - NHS Choices". NHS Choices. 7 October 2014. 
  5. ^ "Low sperm count". NHS Choices. 2 August 2016. 
  6. ^ a b c d Baazeem, Abdulaziz; Belzile, Eric; Ciampi, Antonio; Dohle, Gert; Jarvi, Keith; Salonia, Andrea; Weidner, Wolfgang; Zini, Armand (2011-10-01). "Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair". European Urology. 60 (4): 796–808. doi:10.1016/j.eururo.2011.06.018. PMID 21733620. 
  7. ^ a b c d e Eisenberg, Michael L.; Lipshultz, Larry I. (2011-01-01). "Varicocele-induced infertility: Newer insights into its pathophysiology". Indian Journal of Urology : IJU : Journal of the Urological Society of India. 27 (1): 58–64. doi:10.4103/0970-1591.78428. ISSN 0970-1591. PMC 3114589Freely accessible. PMID 21716891. 
  8. ^ Hayden, Russell P.; Tanrikut, Cigdem (2016-05-01). "Testosterone and Varicocele". The Urologic Clinics of North America. 43 (2): 223–232. doi:10.1016/j.ucl.2016.01.009. ISSN 1558-318X. PMID 27132580. 
  9. ^ Dabaja, Ali; Wosnitzer, Matthew; Goldstein, Marc (2013-08-01). "Varicocele and hypogonadism". Current Urology Reports. 14 (4): 309–314. doi:10.1007/s11934-013-0339-4. ISSN 1534-6285. PMID 23754533. 
  10. ^ Salam, MA (2013). Principles and Practice of Urology. New Delhi 110 002, India: Jaypee Brothers Medical Publishers. p. 752. ISBN 978-93-5025-260-4. 
  11. ^ Kroese, A. C. J.; Lange, N. M. de; Collins, J. A.; Evers, J. L. H. (2013-07-01). "Varicocele surgery, new evidence". Human Reproduction Update. 19 (4): 317–317. doi:10.1093/humupd/dmt004. PMID 23515200. 
  12. ^ Li, Fuping; Yue, Huanxun; Yamaguchi, Kohei; Okada, Keisuke; Matsushita, Kei; Ando, Makoto; Chiba, Koji; Fujisawa, Masato (2012). "Effect of surgical repair on testosterone production in infertile men with varicocele: A meta-analysis". International Journal of Urology. 19 (2): 149–54. doi:10.1111/j.1442-2042.2011.02890.x. PMID 22059526. 
  13. ^ Kroese, AC; de Lange, NM; Collins, J; Evers, JL (17 October 2012). "Surgery or embolization for varicoceles in subfertile men". The Cochrane database of systematic reviews. 10: CD000479. doi:10.1002/14651858.CD000479.pub5. PMID 23076888. 

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External resources