Perhaps there is no more confusing and controversial disease in urology – in terms of diagnosis, treatment and analysis of the consequences – than varicocele.
Varicocele is an extension of the loziform (uviform) venous plexus of the scrotum.
The ICD-10 code: I-86 – “varicose veins of other localizations”.
It is believed that varicocele causes infertility in men, due to the overflow of excess blood scrotum (as a result of impaired venous outflow), which leads to overheating of the testicle and increased venous pressure, depression of Sertoli cells in the testicle, reducing the total number of sperm and decrease their mobility.
Varicocele occurs in 12% of men, of which 25% have abnormalities in the spermogram , which reduces the ability to have children. But the erection and potency, the disease is not affected. According to some reports, men with impaired reproductive function, in 50% of cases, suffer from varicocele in varying degrees of severity.
- hereditary weakness of the walls of the veins of the spermatic cord and scrotum;
- congenital atony of the “testicle” muscle segment, which is adjacent to the spermatic vein;
- genetic weakness of the valve mechanisms of interested veins;
- disruption of the relationship between the mesenteric artery and the renal vein;
- compression of the internal spermatic vein, such as a tumor.
- long vertical position (“standing” work);
- lifting weights;
- scrotal injury;
- flat feet (as a result of constant overstrain of the legs, venous outflow from the veins of the lower extremities and pelvis is disturbed);
- chronic constipation (impaired venous outflow as a result of increased intra-abdominal pressure);
- congenital heart defects (lead to impaired venous outflow in a large circle of blood circulation, contribute to the development of weakness of the vascular wall of the veins).
Some believe that varicocele is associated with
- prostate adenoma (BPH),
- low testosterone levels.
In fact, it is not. We are talking about independent urological diseases that are not related to varicocele.
Which doctor to go
If you suspect varicocele should consult a urologist or andrologist.
Varicocele can be suspected by any man. Adolescents from the age of 14 are subject to compulsory examination (it is from this age that the disease begins to manifest itself). When puberty under the action of hormones increases blood flow in the testicles and spermatic cord.
If you suspect varicocele should pay attention:
- the presence in the left scrotum of loose venous growths, well perceptible to palpation;
- to reduce the size of one testicle;
- unpleasant sensations (itching, tingling), pain in the testicle of a pulling and pressing nature, aggravated by exercise and sex, after a bath or a sauna. Pain can be given to the left or right lower limb, perineum, lumbar region, to the inguinal region.
- absence of pregnancy in a spouse with regular sex life for 12 months.
In addition, there are a number of symptoms that can not always be determined on their own:
- an increase in the scrotum on the side of the lesion, in a standing position (even with a diminished testicle) against the background of the Valsava sample ( straining of the abdomen in the lower parts after breathing on inspiration);
- the presence of blood (red blood cells) in the semen and urine (microhematuria).
In the late stage of the disease, neuralgia of the spermatic cord nerves joins – the pain intensifies even at rest. Against the background of a pronounced pain syndrome, the intensity of sexual activity may decrease, depressive states occur.
After examination, the urologist usually prescribes:
- Ultrasound scrotum;
- sperm research
You can do this research yourself, and after the results of the study, consult a doctor.
Confirmation of varicocele on ultrasound
When performing an ultrasound of the scrotum, signs of varicocele are convoluted anechoic (not reflecting ultrasound) structures near the testicle.
Enlarged consider the veins with a diameter of more than 3 mm at rest and more than 4 mm when performing a Valsalva test ( straining of the abdomen in the lower parts after breathing on inspiration).
There may be a slowdown of the blood flow in the veins concerned, right up to its complete stop (stasis), with stress tests, the appearance of a reverse (retrograde) blood flow is possible.
Semen in varicocele
By sperm, you can identify the nature of violations of the reproductive function of men. Perhaps a decrease in the total number of sperm ( oligozoospermia ), a decrease in the concentration of normal forms ( teratozoospermia ), loss of sperm motility ( asthenozoospermia ).
Additional diagnostic methods
The size of the testicle is determined by simple devices – comparative ovals ( Prader’s orchidometer ) and elliptic rings ( Tokihara orchidometer ).
To clarify the diagnosis, more detailed detection of blood flow disorders in the testicle being examined, color dopplerography is performed – a type of ultrasound that allows for more accurate diagnosis of vascular lesions and measuring blood flow velocity in certain areas of the compromised veins, determining the localization of thrombosis, if present, which is important for future operative treatment.
In difficult cases, use radiopaque research methods:
- retrograde (reverse) renal-ovarian venography;
- transcrotal testicle phlebography (through the scrotum);
- antegrade venography (through the cremasteric vein and the vein of the vas deferens).
These studies allow us to estimate the degree of dilatation of the spermatic cord, testicular vein, the length of the lesion, the number of branches (collaterals), and the tactics of surgical treatment.
Computer studies play a definite role in doubtful cases : MSCT – multispiral computed tomography and MRI – magnetic resonance imaging.
What can be confused varicocele
Differential (comparative) diagnosis of varicocele is carried out with the following diseases:
- dropsy testicle ( hydrocele );
- tumors of the testicle and other urogenital organs that disturb blood flow;
- inflammation of the epididymis;
- inflammation of the spermatic cord.
There are five degrees of varicocele by ultrasound (according to the author – Sarteschi ), which does not correspond to the clinical classification of the world health organization, which provides for 3 degrees. This is a source of discrepancies and bewilderment in patients and their relatives, especially when it comes to the medical commission before serving in the army or the Ministry of Internal Affairs. The doctor considers these classifications to determine the extent of the disease. It is necessary to understand that the clinical classification prevails, and ultrasound diagnostics is an additional study.
Varicocele degrees by ultrasound
- Grade I – the veins are not dilated, but the reverse blood flow is determined during the Valsalva test.
- Grade II – narrowing of the veins at the upper pole of the testicle, the reverse flow of blood is determined during the Valsalva maneuver.
- Grade III – expansion of the veins to the lower pole of the testicle in the standing position, the reverse flow of blood is determined during the Valsalva test , the testicle size is normal.
- IV degree – dilation of the veins to the lower pole of the testicle in the prone position, the reverse blood flow is determined during the Valsalva test , the testicle is reduced in size.
- V degree – dilatation of the veins to the lower pole of the testicle in the prone position, during the Valsalva test, there is no reverse blood flow, the testicles are sharply reduced in size, atrophic (small and flabby).
Degrees of varicose veins of the uviform plexus according to WHO (World Health Organization) classification
- I degree: varicose veins is determined only by palpation.
- Grade II: varicose veins can be clearly seen with the naked eye.
- Grade III: Varicose cluster falls below the lower edge of the testicle.
When determining the stage, i.e. stages of the disease for convenience, the classification of Academician Lopatkin is mainly used: (approx. – recognized world authority in urology).
- Stage I: varicose veins are detected only when Valsava is tested (when straining ) in a standing position by palpation;
- Stage II: varicose veins can be clearly seen, but the size and elasticity of the testicle is normal.
- Stage III: determined by a sharp decrease in the testicle and the loss of its elasticity against the background of pronounced varices.
Localization of varicocele, there are the following types:
- Left-sided (found in the vast majority of cases) – develops with the defeat of the veins of the left testicle;
- Right (rare location): detected in violation of the outflow from the venous plexus of the right testicle; Probable cause of right-sided varicocele can be compression of the inferior vena cava with a tumor of the right kidney.
- bilateral: veins on both sides of the scrotum can not cope with the outflow of venous blood.
- Tablets: phlebotonics and drugs for blood circulation in the early stages of the disease;
- Exercise therapy – a complex of physical u;
- Compression underwear;
- In the presence of a competent specialist, hirudotherapy has a certain effect (treatment with leeches);
- Surgical treatment according to strict indications.
In the early stages of varicocele, with unexpressed manifestations of the disease, it may well justify itself (up to the disappearance of symptoms) conservative therapy and a special regimen:
Prescribe drugs – phlebotonics ( venoprotectors ). This is primarily:
- Detralex ( phlebodia and its analogues) – the drug contains flavonoids – Diosmin + Hesperidin. These substances with varicocele, help to cope with edema, improve blood circulation, improve the tone of the veins in the right area, reduce pain.
The course of treatment is from 3 months to 1 year. Possible repeated course of therapy.
Important are drugs that improve blood circulation:
- pentoxifylline ( trental and its analogues) – take courses of 1 month with intervals of 2 – 3 months.
Perhaps a combination with phlebotonics.
Important! Analgesics can only be taken temporarily with severe pain with short courses.
Ineffective but popular remedies.
Quite contradictory information about the use of such drugs as:
Antibiotics, direct anticoagulants, Viagra are not shown at all.
The effect of homeopathic medicines, herbal lotions and various “miraculous” ointments is doubtful.
Sport, exercise therapy and varicocele bath
Testicle massage and special therapeutic physical culture have a definite effect. It helps to improve blood circulation in problem areas, improve the tone of the veins.
The most effective exercise physical therapy:
- “Bicycle”, lying on his back;
- Rotation of the pelvis;
- Swing your legs in different directions, lying on your back;
- Squats squatting;
- Tilt forward, reaching for the floor with your hands.
You can engage in sports, but eliminates excessive physical exertion, especially in strength exercises, aimed at increasing intra-abdominal pressure (exercises with weights in an upright position).
In order to affect the muscle that lifts the testicle, they use tempering procedures: a contrast shower, daily scrubbing of the scrotum with a cool towel.
Visiting baths and saunas is undesirable. Alcohol is excluded, eating spicy foods, sex is not contraindicated, but in case of pain syndrome sexual excesses should be limited.
It is recommended to wear special elastic underwear from high-quality knitwear with the addition of modal and elastane . Such underwear with varicocele helps maintain the scrotum in the upper position, removes excess venous load, improves blood flow, prevents pain. Briefs should be selected in size, be sufficiently dense, but not squeezing the testicles.
Sometimes hirudotherapy (leech therapy) shows good results. It improves blood circulation in the area of the testicles and the spermatic cord, tones the veins, eliminates pain. It should be understood that this treatment can be carried out only by qualified specialists, long courses of such therapy are required, the risk of bleeding is high.
The purpose of surgery for varicocele is to stop the reverse flow of blood through the testicular vein. The operation is performed by a urologist.
In the USSR, the question of surgical treatment of varicocele was decided from the position of the administrative-command system. All adolescents with the established diagnosis of “varicocele”, regardless of its degree, were subject to mandatory surgical treatment before being recruited into the Soviet Army (at the age of 18). No one could have avoided the operation, except by invoking the intolerance of all, without exception, medicines. Operations were performed on boys from 12–14 years old. Parents did not resist – they were told that in the future their son could be left without his own children. At the same time, sperm analysis was not done, and reproductive disorders were not strongly understood. Nowadays, this practice is becoming a thing of the past, but in some places there are vestiges of the old system.
Indications for surgery
Given the fact that the benefits of surgical intervention for varicocele are ambiguous, surgical treatment should be carried out according to the most stringent indications, based on the following criteria:
- the duration of the barren period in marriage must be at least one year with regular sexual life;
- varicocele must be confirmed by all physical and instrumental methods;
- the affected testicle should be reduced in size;
- there must be a reduction in sperm parameters;
- FSH (follicle-stimulating hormone) levels should not exceed the upper values - 12 mU / l;
- the spouse (partner) should be well examined, with intact ovulation, tubal patency;
- cosmetic target;
- pronounced pain syndrome with a tendency to progression.
You should also take into account that the percentage of conception with a waiting tactic is 16%, and in vitro fertilization, where the sperm of patients with varicocele was taken – already 35%.
Types of surgical interventions
- Open ligation of the testicular vein ( Ivanissevich operation );
- Operation Marmara or Palomo;
- Laparoscopic ligation of the testicular vein;
- Endovascular embolization.
The indications for surgical treatment and the method are determined by the attending physician, the urologist-andrologist, preferably together with the fertility specialist , on the basis of all the data obtained, the degree of branching of the plexus, and other individual patient characteristics. Many decide in this matter the operational skills of the doctor.
Ligation of spermatic vein open
( Ivanissevich’s operation , proposed by him in 1918) – is performed in the usual way, by layer-by-layer dissection of tissue with a scalpel.
How is the operation?
Preparation includes emptying the bowels and shaving the body in the area of the surgical field just before the operation (the nurse will warn you about this).
The operation resembles intervention in appendicitis, in the groin, only from the opposite side, is performed under general or spinal anesthesia and takes no more than 40 minutes.
- On the second day after surgery, you can sit down carefully.
- The hospital stay is 5-7 days.
- The hospital is monitored, daily dressings, treatment of postoperative wounds with special antibacterial solutions. For this period, the sick-list is laid and about a week, depending on the state – for follow-up care in the clinic.
- The rehabilitation time is 2-3 weeks (you can not lift weights more than 5 kg).
- The stitches are removed for 6-7 days, it does not hurt. The scar on the skin is small, unobtrusive.
- It may persist for some time in the groin, sometimes a slight temperature rises, but these phenomena quickly pass.
- In a month you can practice your favorite sport, but with gentle loads for 3-4 months.
Modification operation Ivanissevicha is microsurgical operation Marmara when the is very small – 2 cm incision and spermatic cord is extracted to the outside, where the extended intersect Vienna. This reduces the invasiveness of the operation, the time spent in the hospital and the time of rehabilitation.
A rarer variation of the classical Ivanissevich operation is the Palomo operation, when the incision is made above the inguinal canal. It is preferable to do it to those people in whom the testicular vein does not branch and requires a single ligation.
Ligation testicular vein laparoscopic (by using special optical instruments and manipulators through small holes in the skin of the anterior abdominal wall, in order to lower tissue traumatization).
After this operation, an even smaller rehabilitation period.
And in fact , and in another case it is possible to use different approaches to enter the testicular vein: retroperitoneal, inguinal, subinguinal . The choice of access depends on the individual characteristics of the patient and the skills of the urologist.
Endovascular embolization (blockage) of the testicular veins with a special embolus is possible . This is a “one day” operation.
The rehabilitation period is minimal. However, the sick leave was put on this intervention. Embolization for varicocele can be performed by both a urologist and an x-ray surgeon.
How is the operation?
The operation is performed as follows: under local anesthesia, a small incision is made in the groin area on the right (when the varicocele is on the left), then a thin tube (catheter) is inserted into the femoral vein, it is gradually advanced under x-ray control until it reaches the left testicular vein. Further, an embolus is inserted into the testicular vein , a device blocking the blood flow. There are a number of different emboli : ivalone fillings (plastic version), cyanocrylate adhesives – N-butyl-2-cyanoacrylate superglue (NBCA ), silicone balloons, metal occludermes , occlusal coils. All of these devices are somewhat different in their method of installation, but the main goal, the cessation of blood flow through the testicular vein , is regularly carried out . After the embolus has been established, a radiopaque substance is inserted through the catheter in order to control the complete overlap of the blood flow, the catheter is removed, the incision is sutured.
Important! Despite the improvement of equipment and technology of operations, surgery on the testicular vein, according to many serious foreign studies, does not lead to an increase in the number and mobility of spermatozoa.
Surgical treatment may be complicated
- dropsy testicle
- hematoma of the groin,
- swelling of the scrotum.
There is a possibility of recurrence (repeat) of varicocele, which is associated with an underestimation of the development of the varicose network and collaterals (messages).
Various complications are:
- with open operations – 1%
- after laparoscopic interventions – 4%,
- when installing emboli – 10-15%.
Note: indeed, with open operations, the complications are the least, according to the available statistics.
In the absence of treatment, it is unfavorable, since the disease is prone to progression, often causes male infertility, especially if there are predisposing factors (heredity, constant work with weights in an upright position, frequent overheating of the testicle).
With timely treatment, the prognosis is favorable, but it should be understood that getting rid of varicocele does not guarantee the normalization of spermogram.
As a rule, with grades I and II (according to WHO classification), the medical draft board will decide in favor of the service. At the III degree, the status of “limited health condition” is assigned.