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Cross section showing the pampiniform plexus
|Classification and external resources|
Cross section showing the pampiniform plexus
|Classification and external resources|
A varicocele // is an abnormal enlargement of the pampiniform venous plexus in the scrotum. This plexus of veins drains 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. Upward flow of blood in the veins is ensured by small one-way valves that prevent backflow. Defective valves, or compression of the vein by a nearby structure, can cause dilatation of the testicular veins near the testis, leading to the formation of a varicocele. Varicocele is known as one of the main causes for male infertility and can be treated by a surgery or non-surgical treatments.
Symptoms of a varicocele may include:
The idiopathic varicocele occurs when the valves within the veins along the spermatic cord do not work properly. This is essentially the same process as varicose veins, which are common in the legs. This results in backflow of blood into the pampiniform plexus and causes increased pressures, which on rare occasion can lead to permanent damage to the testicular tissue due to disruption of normal supply of oxygenated blood via the testicular artery.
Varicoceles develop slowly and may not have any symptoms. They are most frequently diagnosed when a patient is 15–30 years of age, and rarely develop after the age of 40. They occur in 15-20% of all males.
A majority of idiopathic varicoceles occur on the left side, because the left testicular vein travels superiorly and connects to the left renal vein (at a 90-degree angle), while the right testicular vein drains directly into the inferior vena cava. Isolated right sided varicoceles are rare.
A secondary varicocele is due to compression of the venous drainage of the testicle. A pelvic or abdominal malignancy is a definite concern when a unilateral right-sided varicocele is newly diagnosed in a patient older than 40 years of age. One non-malignant cause of a secondary varicocele is the so-called "Nutcracker syndrome", a condition in which the superior mesenteric artery compresses the left renal vein, causing increased pressures there to be transmitted retrograde into the left pampiniform plexus. The most common cause is renal cell carcinoma (a.k.a. hypernephroma) followed by retroperitoneal fibrosis or adhesions.
The term varicocele specifically refers to dilatation and tortuosity of the pampiniform plexus, which is the network of veins that drain the testicle. This plexus travels along the posterior portion of the testicle with the epididymis and vas deferens, and then into the spermatic cord. This network of veins coalesces into the gonadal, or testicular, vein. The right gonadal vein drains into the inferior vena cava, while the left gonadal vein drains into the left renal vein at right angle to the renal vein, which then drains into the inferior vena cava. One of the main functions of the plexus is to lower the temperature of the testicles; vericocele causes this function to be lost, hence the most common complication of untreated vericocele is higher temperature of the testes, resulting in testicular atrophy causing infertility.
The small vessels of the pampiniform plexus normally range from 0.5–1.5 mm in diameter. Dilation of these vessels greater than 2 mm is called a varicocele.
Recent studies have shown that the detrimental effect of varicocele on sperm production is progressive and due to reduction in supply of oxygenated blood and nutrient material to the sperm production sites, which persistently reduces the quality and the quantity of the sperms, leading to reduction in their fertility capacity with time.
Blood from the testes that cannot drain via the pampiniform plexus may route through the prostate in a process known as communicating vessels. The increased flow of blood to the prostate can lead to congestion and enlargement of the gland (BPH) both through physical mechanisms and as a result of "accelerated prostate cell proliferation [growth] resulting from the extremely high concentration of free testosterone reaching directly from the testes to the prostate".
Upon palpation of the scrotum, a non-tender, twisted mass along the spermatic cord is felt. Palpating a varicocele can be likened to feeling a bag of worms. When one is lying down, gravity may allow the drainage of the pampiniform plexus and thus make the mass not obvious. This is especially true in primary varicocele, and absence may be a sign for clinical concern. The testicle on the side of the varicocele may or may not be smaller compared to the other side.
Varicocele can be reliably diagnosed with ultrasound, which will show dilation of the vessels of the pampiniform plexus to greater than 2 mm. The patient being studied should undergo a provocative maneuver, such as Valsalva's maneuver (attempting expiration against a closed airway) or standing up during the exam, both of which are designed to increase intra-abdominal venous pressure and increase the dilatation of the veins. Doppler ultrasound is a technique of measuring the speed at which blood is flowing in a vessel. An ultrasound machine that has a Doppler mode can see blood reverse direction in a varicocele with a Valsalva, increasing the sensitivity of the examination.
Recent studies have shown that varicocele is a bilateral disease and the diagnosis of the right side is missed by physical examination and even by ultrasonography. The examination should be performed by ultrasonography — color flow doppler performed by highly experienced sonographer or radiologist that will diagnose varicocele by demonstrating back-flow in the right and in the left spermatic veins.
Varicocelectomy, the surgical correction of a varicocele, is performed on an outpatient basis. The three most common approaches are inguinal (groin), retroperitoneal (abdominal), and infrainguinal/subinguinal (below the groin). Various other techniques may be used. Ice packs should be kept to the area for the first 2 days after surgery to reduce swelling. The patient may be advised to wear a scrotal support for some time after surgery.
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.
In the Gat-Goren nonsurgical method for treating varicoceles, performed under local anesthesia, a catheter is inserted through a vein in the upper thigh. Fluid injected through the catheter selectively closes off the malfunctioning veins, thus enabling the testicular tissues to recover and begin to produce normal sperm in normal amounts. The procedure lasts one to two hours and causes almost no discomfort. The patient can return to his regular routine within 24 hours.
An alternative to surgery is embolization, a minimally invasive treatment for varicocele that is performed by an interventional radiologist. This involves passing a small wire through a peripheral vein and into the abdominal veins that drain the testes. Through a small flexible catheter, the doctor can obstruct the veins so that the increased pressures from the abdomen are no longer transmitted to the testicles. The testicles then drain through smaller collateral veins. The recovery period is significantly less than with surgery and the risk of complications is minimized with overall effectiveness similar to surgery, yet with fewer recurrence rates. However, radiation exposure to the testicles can often not be avoided with this technique.
Embolization is an effective treatment for post-surgical varicoceles. These are varicoceles that reappear after they have been surgically repaired. The main theory is the presence of redundant gonadal veins that provide collateralization cause the reappearance of the varicoceles. The use of NBCA glues during the embolization is as effective at embolizing these collaterals as coils.
Medical treatment with L-carnitine has some beneficial effect on sperm parameters, but is not as effective as surgery. Micronised purified flavonoid fractions (MPFF)(Daflon) have a beneficial effect on reducing varicocele pain and reducing reflux time of left spermatic vein during the Valsalva maneuver.
Natural treatment methods typically involve improving blood circulation in the lower torso, e.g. by alleviating constipation, reducing inflammatory effects, and lowering blood viscosity These methods could involve dietary supplementation, various exercises like swimming and cooling of the scrotum
A Cochrane review in 2013 grossly estimated that when performing surgical or radiological treatment of varicocele in subfertile men with a clinically manifest varicocele and poor semen quality, one additional pregnancy will be obtained for approximately every 7 men treated.[clarification needed]
A meta-analysis in 2011 of the available literature concluded that varicocelectomy improves sperm parameters (count and total and progressive motility), reduces sperm DNA damage and seminal oxidative stress, and improves sperm ultramorphology. Studies also indicate that a microsurgical approach to a varicocele repair results in less recurrence and fewer complications than other techniques.
Surgical treatment is generally reserved for those with symptomatic varicocele, a discrepancy in testicular size or marked semen abnormalities in patients with a palpable varicocele at rest. There are also non-invasive natural treatment options that may relieve symptoms.
Varicocele can be harmless, but in some cases it can cause infertility and pain. Although there are studies showing improvement in sperm quality in 57%, there are also studies showing that the regular surgery has no significant effect on infertility. Thus the surgery may not improve fertility and the patient will need to undergo a nonsurgical treatment.