What Are the Different Types of Varicocele Treatment?

Varicocele (VC) is a vascular disease that refers to the abnormal expansion, elongation and tortuosity of the venous plexus in the spermatic cord, which can cause pain and discomfort and progressive hypofunction of the testis. It is a common cause of male infertility one. It is widely concerned for its related scrotal pain and discomfort, infertility and testicular atrophy. Is a common male urogenital disease. More common in young adults, the incidence of 10% to 15% of the normal male population, and 19% to 41% of male infertility. Varicocele varicocele is a disorder of vascular spermatozoa caused by the expansion of the spermatic cord and the venous plexus surrounding the spermatic cord. It is usually seen on the left side, accounting for 77% to 92%, and can also develop bilateral disease, accounting for 7% to 22%. Rarely, it occurs on the right side, accounting for about 1%. Traditional surgery uses an inguinal incision to ligate the internal spermatic vein and remove the dilated vein in the scrotum.

Basic Information

English name

varicocele

Visiting department

Urology

Multiple groups

Young male

Common causes

Dilation of the spermatic cord and the venous plexus

Common symptoms

Generally without symptoms.

Contagious

no

Causes of varicocele

According to the cause, it can be divided into two types: primary and secondary VC.

Primary VC

The varicocele of the left spermatic cord is more common than the right. The reasons may be: the increased pressure in the venous vein, because the left spermatic cord has a long stroke and merges into the left renal vein at a right angle; "nutcracker" phenomenon (NCS), mesentery The upper arteries and aorta compress the left renal vein, affecting the return of the left internal spermatic vein and even causing reflux, the "nutcracker" phenomenon (NCS); weak connective tissue around the internal spermatic vein and the lack of venous valves are common in the left side.

Relevant factors for the occurrence of primary varicocele: The absence or dysfunction of the varicocele valve leads to blood reflux; the venous wall of the varicocele and the surrounding connective tissue are weak, or anatomical factors such as dystrophy of the cremaster muscle. Upright posture affects venous return of spermatic cord.

2. Secondary VC

Etiology and diseases include: left renal vein or vena cava tumor thrombus obstruction, renal tumor, intraperitoneal or retroperitoneal tumor, left renal vein or vena cava tumor thrombus obstruction, renal tumor, pelvic tumor, huge hydronephrosis, ectopic blood vessel compression Ascending spermatic cord and so on.

Clinical manifestations of varicocele

Patients often fail to receive timely diagnosis and treatment due to lack of conscious symptoms, which eventually leads to impaired spermatogenesis in some patients. A small number of patients may have scrotal swelling during standing, local or intermittent scrotum pain, faint pain, and dull pain, radiation to the lower abdomen, groin area, or back waist, symptoms worsened after exertion or long standing and walking, supine Symptoms ease or disappear after rest.

Varicocele examination

Physical examination

Examine the scrotum and its contents, including standing and supine positions, and perform Valsalva test in standing position to understand whether the patient has tortuous and dilated venous mass. Tests include testicular size and texture, epididymis, vas deferens, seminiferous cord and its blood vessels. Small and soft testicles are a sign of testicular insufficiency. The use of staining methods and strict morphological analysis of the sperm in accordance with WHO standards is helpful for the evaluation of fertility impairment in infertile patients, and is also conducive to standardized operations and uniform analysis standards.

2. Imaging examination

(1) Color Doppler ultrasound color Doppler ultrasound is of great value in the diagnosis and typing of varicocele. Its sensitivity and specificity are high. It can also be found in infertile patients. Many patients with subclinical varicocele have become the preferred auxiliary examination method for varicocele.

(2) CT and MRI are only available for the diagnosis and differential diagnosis of secondary varicocele.

3. Testicular function evaluation

(1) Testicle size and texture: Testicle size and texture are susceptible to subjective factors. Testicle size can be measured by Prader testicular measurement or color Doppler ultrasound, but the former is likely to overestimate testicular volume, especially in the case of small testes . It is generally believed that the total volume of bilateral testicular ultrasound with normal spermatogenic function is at least 20 mL under ultrasound, and the total volume of Prader testicular measuring instrument is at least 30-35 mL. For adolescent patients with varicocele, vernier calipers and color Doppler ultrasound can be used to measure testicular size and calculate testicular atrophy index. Testicular atrophy (AI)> 15% to determine whether the testicles have atrophy, atrophy index = (right testicular volume-left testicular volume) / right testicular volume × 100%.

(2) Semen examination: Semen examination is recommended for infertile patients or those with fertility requirements. It is recommended to have two consecutive examinations within 3 weeks. The inspection items should include: semen volume, liquefaction time, pH value, sperm concentration, morphology, activity rate, etc.

(3) Serum testosterone: Serum total testosterone can be tested, and serum free testosterone or biologically active testosterone can be tested under conditions.

(4) Other hormones: FSH, LH, PRL, androgens, and serum somatostatin B (optional).

(5) Testicular biopsy.

Varicocele diagnosis

At present, the more accurate diagnostic method is color Doppler flow imaging. Routine semen examinations show that patients with low sperm density, low viability, low vitality, and high deformity are recommended to perform color Doppler flow imaging (CDFI) examination. CDFI can intuitively and accurately observe the spermatic varices. The degree of expansion and the state of blood flow are currently non-invasive and accurate diagnostic methods. The clinical diagnostic criteria of CDFI are:

1. At least three spermatic cord veins were detected in the spermatic cord venous plexus of calm VC under clinical breathing. One of them had a diameter greater than 2.0 mm or the diameter of the vein increased significantly when abdominal pressure was increased, or venous blood after Valsalva test Marked reflux

2. The subclinical VC spermatic cord has a vein diameter of 1.8mm, and there is no blood reflux in calm breathing. The Valsalva test has reflux, and the reflux phase is 800ms.

Differential diagnosis of varicocele

Physical examination and color Doppler ultrasound can basically diagnose varicocele. However, attention should be paid to identifying varicocele with other diseases, such as scrotal discomfort, pain, and fertility caused by chronic pelvic pain syndrome. Special attention should be paid to the identification of psychological disorders with physical symptoms as the main manifestation.

Varicocele treatment

Treatment should be based on whether the patient is accompanied by infertility or abnormal semen quality, whether there are clinical symptoms, the degree of varicose veins, and other complications. Treatment methods include general treatment, medication, and surgery. Surgical treatment is the main treatment method, which can achieve the ideal treatment effect.

General treatment

Including lifestyle, diet adjustment, physical therapy, such as: smoking cessation and alcohol restriction, light diet, avoiding exercise to increase abdominal pressure; cooling therapy or scrotum care.

2. Drug treatment

(1) Drugs for varicocele

1) Aescin: Anti-inflammatory, anti-exudation, and protection of the collagen fibers of the vein wall can gradually restore the elasticity and contraction of the vein wall, increase the speed of venous blood return and reduce venous pressure.

2) Flavonoids: anti-inflammatory and anti-oxidant effects, which can increase venous tension, reduce capillary permeability, increase lymphatic recirculation rate, reduce edema, and improve pain symptoms caused by clinical varicocele.

(2) Drugs to improve symptoms: Non-steroidal anti-inflammatory drugs such as ibuprofen can be used for local pain and discomfort.

(3) Drugs for improving semen quality: For patients with varicocele who have impaired reproductive function and have fertility requirements, drugs that promote spermatogenesis and improve semen treatment can be used.

3. Surgical treatment

First, secondary factors such as renal tumors, hydronephrosis, retroperitoneal tumors, and ectopic blood vessels should be excluded. Surgical treatment of varicocele includes surgical treatment and interventional treatment (antegrade or retrograde).

Surgical treatment includes traditional transinguinal route, transperitoneal route, sub-inguinal route spermatic vein ligation, micro-technical groin route or sub-inguinal spermatic vein ligation, laparoscopic spermatic vein ligation, and so on.

Patients with primary VC accompanied by infertility or abnormal semen are indications of treatment regardless of the severity of the symptoms. Current surgical treatment includes high inguinal ligament ligation via inguinal canal, laparoscopic surgery, and high ligament ligation via retroperitoneal spermatic vein. Intravenous embolization of spermatic cord. Compared with transinguinal and laparoscopic surgery, high ligation of the spermatic cord with retroperitoneum has less surgical trauma, less damage to other blood vessels, and less leakage of the spermatic cord. The operation time is short, the cost of surgery is low, and postoperative complications recur. Low rate and other advantages, is the preferred treatment for unilateral varicocele.

The improvement of semen parameters in patients with surgery combined with medication was significantly better than that of surgery alone.