Varicocele
From Freepedia
Varicocele is a mass of enlarged veins in the scrotum that develops in the spermatic cord, which leads from the testicles (testes) up through a passageway in the lower abdominal wall (inguinal canal) to the circulatory system. The spermatic cord is made up of blood vessels, lymphatic vessels, nerves, and the duct that carries sperm from the body (vas deferens). If the valves that regulate bloodflow from these veins become defective, blood does not circulate out of the testicles efficiently, which causes swelling in the veins above and behind the testicles.
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Definition
The term varicocele 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 vein. The right gonadal vein drains into the inferior vena cava, while the left gonadal vein drains into the left renal vein, which then drains into the inferior vena cava.
The small vessels of the pampiniform plexus normally range from 0.5-1.5 mm in diameter. Dilatation of these vessels greater than 2 mm is called a varicocele.
Etiology
The idiopathic varicocele occurs when the valves within the veins along the spermatic cord don't 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, ultimately leading to damage to the testicular tissue.
Varicoceles usually develop slowly and may not have any symptoms. There are most frequently diagnosed when a patient is 15-25 years of age, and rarely develop after the age of 40. They occur in 15-20% of all males, and in 40% of infertile males.
98% of idiopathic varicoceles involve the left testicle, and 70% of patients with varicocele have them bilaterally. Isolated right sided varicoceles are rare, and should prompt evaluation for an abdominal or pelvic mass (see secondary varicocele, below).
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 varicocele is newly diagnosed in a patient older than 40 years of age. A non-malignant cause of a varicocele is the so-called "nut-cracker SMA" (superior mesenteric artery), a condition in which the superior mesenteric artery compresses the left renal vein, causing increased presses there to be transmitted retrograde into the left pampiniform plexus.
Symptoms
- Visible, enlarged, twisted veins in the scrotum
- Infertility
- A painless testicle lump, scrotal swelling, or bulge within the scrotum, more common on the left side
- Lump will disappear when sufferer is in horizontal (laying down) position due to lack of gravitational pull on the blood
Diagnosis
Upon palpation of the scrotum, a non-tender, twisted mass along the spermatic cord is felt (it feels like a bag of worms.) However, the mass may not be able to be felt or obvious, especially when lying down. 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 dilatation of the vessels of the pampiniform plexus to greater than 2 mm. The patient being studied should undergo a provocative maneuver, such as a Valsava maneuver (straining, like he is trying to have a bowel movement) or standing up during the exam, both of which are designed to increase intraabdominal 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 Valsava, which increases the sensitivity of the examination.
Treatment
Varicoceles may be managed with a scrotal support (e.g. Jockstrap, Briefs). However, if pain continues or if infertility or testicular atrophy results, the varicocele may need to be surgically ligated (tied off).
Varicocelectomy, the surgical correction of a varicocele, is performed on an outpatient basis. The cut is usually made in the lower abdomen, although various techniques can be used. Ice packs should be kept to the area for the first 24 hours 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 (blood clot formation), infection, or injury to the scrotal tissue or structures. In addition, injury to the artery that supplies the testicle may occur.
An alternative to surgery is embolisation, a non-invasive treatment for varicocele which is performed by a specialized physician called 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, this 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 a bunch of smaller, collateral veins. The recovery period is significantly less than with surgery and the risk of complications are minimised. However, overall effectiveness is not as high as surgery, which can still remain an option.
Prognosis
A varicocele is usually harmless and sometimes requires no treatment. If surgery is required because of infertility or testicular atrophy, the outlook is usually excellent. Removal of varicocele can lead to normal testicle temperatures and an increased sperm rate.
Source
- Varicocele. MedlinePlus Medical Encyclopedia. US Federal Government public domain. Update Date: 12 November 2003. Updated by: Scott M. Gilbert, M.D., Department of Urology, Columbia-Presbyterian Medical Center, New York, NY. Review provided by VeriMed Healthcare Network.
- Diagnostic Ultrasound, wnd Ed. Rumack, Wilson, Charboneau (ed.) Mosby 1998.
External links
- Patient UK has a nice patient orientated, but detailed explanation of Varicoceles
- The Royal College of Radiologists has good information on Varicocele Embolisation
