Varicocele is a varicose change in the veins of the spermatic cord, accompanied by a violation of venous outflow from the testicle. It is manifested by pulling and bursting pains, a feeling of discomfort and heaviness in the scrotum, visible expansion of veins. There may be inflammation or rupture of varicose vessels with hemorrhage in the scrotum. Progressive varicocele leads to a decrease in the size of the affected testicle, a violation of spermatogenesis, the development of early male menopause and infertility. Diagnosis - ultrasound of the scrotum with Dopplerography. Treatment can be minimally invasive (vascular embolization) or surgical, carried out by various methods.
Varicocele is a disease caused by varicose veins of the spermatic cord. By itself, varicocele does not threaten the patient's life and, as a rule, does not cause him much concern. The main danger of varicocele is that the disease can lead to the development of male infertility. When analyzing the ejaculate, disorders of spermatogenesis are determined in 20-70% of patients with varicocele. There is confirmed evidence of a correlation between the degree of impaired sperm production and the duration of the disease. In some cases, varicocele is accompanied by pain syndrome of varying intensity.
According to WHO, varicocele affects 15-17% of men. The incidence rate can vary significantly depending on age and place of residence. At the age of 14-15 years, varicocele is detected in 19.3% of adolescents, when conscripted for military service – in 5-7% of young men. Often, varicocele is practically asymptomatic and men do not seek medical help. During ultrasound, the signs of varicocele are determined in 35% of men who have reached puberty. In the overwhelming number of patients, left-sided varicocele is detected, which is due to anatomical differences in the venous systems of the testicle on the left and right. On the right, varicose veins of the spermatic cord develop in 3-8% of patients, on both sides – in 2-12%.
The reason may be the insufficiently good operation of the valves of the veins of the spermatic cord. Venous valves, which normally prevent the reverse flow of blood, cannot cope with increased pressure under increased load (physical tension, vertical position of the body). Due to the increased pressure, the veins gradually expand, eventually forming tumor-like venous nodes.
Modern studies conducted in the field of phlebology have revealed several causes of primary (idiopathic) varicocele: insufficiency of connective tissue forming the venous wall, underdevelopment or change of the valvular apparatus of regional (testicular and spermatic cord veins) and major veins, or disruption of the formation of the inferior vena cava in the prenatal period.
Certain anatomical features can cause an increase in pressure in the renal vein system. Venous hypertension causes the failure of the valves of the testicular vein. A workaround is gradually developing, in patients, the reverse flow of blood from the renal vein to the testicular vein is detected, and from there to the cluster plexus. An increase in intra-abdominal pressure with prolonged tension of the anterior abdominal wall (constipation, intense physical exertion, constant stay in an upright position) can act as a provoking factor leading to the development of varicocele.
Secondary (symptomatic) varicocele is a complication of the volumetric process in the kidneys, pelvis or retroperitoneal space. In this case, the cause of the development of the disease becomes an obstacle to the normal outflow of blood from the veins of the spermatic cord.
The following degrees of varicocele are distinguished:
The severity of the clinical manifestations of varicocele depends on the degree of venous dilation. At stages 0 and 1 of the disease, there are no symptoms of varicocele. Varicose veins, as a rule, are detected during a preventive examination.
At stage 2 of varicocele, patients complain of pain in the scrotum. The severity of pain can vary significantly. A number of patients note only discomfort when walking, some patients have sharp pains that resemble neuralgic in nature. There may be increased sweating, burning sensation in the scrotum. Many patients with varicocele complain of sexual dysfunction. During the physical examination, the expansion of the veins reaching the lower pole of the testicle and descending below it is determined. The testicle on the affected side descends, leading to asymmetry and sagging of half of the scrotum.
At stage 3 of varicocele, the connection between pain and physical activity disappears. The pain becomes constant, disturbing patients at rest and at night. An external examination reveals numerous clusters of veins. The scrotum increases, its asymmetry becomes more pronounced.
In the absolute majority of cases, the diagnosis of varicocele is not difficult for a phlebologist surgeon. The patient is interviewed to determine the circumstances of the development and prescription of the disease. Pay attention to possible injuries of the lumbar region.
In some cases, an external examination reveals enlarged cluster nodes. The sinuous, worm-like soft veins of the cluster plexus are palpated. In some patients, the testicle on the side of the lesion decreases in size and becomes flabby.
With varicocele, palpatory examination is necessarily carried out in a horizontal, vertical position and with straining (during the Valsalva test). If the dilated veins on the right are not detected when standing and straining, most likely we are talking about a primary varicocele. The dilation of veins with bilateral or right-sided varicocele remaining in a horizontal position may indicate a symptomatic process.
To exclude volumetric formations that cause symptomatic varicocele, ultrasound of the kidneys and retroperitoneal space is mandatory. Vascular thrombosis, as well as diseases leading to the development of secondary varicocele, can be detected during MRI or CT. Patients who have reached the age of majority are prescribed a spermogram (analysis of ejaculate). Often, with varicocele, asthenozoospermia (decreased activity) and oligospermia (decrease in the number) of spermatozoa are detected.
Thermometry, ultrasound of the scrotum, Dopplerography, thermography and rheography are optional diagnostic methods. At the same time, the use of ultrasound and Doppleroscopy is often used to identify subclinical forms of varicocele. To determine the tactics of treatment, contrast studies are performed: retrograde renal-testicular venography, transcrotal testiculophlebography. In some cases, antegrade venography is performed before, during and after surgery.
With secondary varicocele, the underlying disease must be treated. With primary varicocele of 0 and 1 degrees, surgical treatment is not required. Measures are being taken to eliminate stagnation in the pelvis (restriction of physical activity, prevention of chronic constipation, etc.). Sometimes elderly patients have a positive effect when wearing a suspension. With grade 2 varicocele, accompanied by intense pain, and grade 3 of the disease, surgical treatment is necessary. Indications for surgical treatment of varicocele: asthenozoospermia and oligospermia; lagging testicular growth on the side of the lesion during puberty; cosmetic defect.
There are three groups of surgical interventions for varicocele: testicular elevation, varicocele embolization and vein excision. Excision of veins can be performed from subinguinal (at the entrance to the inguinal canal), ingvinal (in the inguinal canal) or retroperitoneal (at the exit of the inguinal canal) access. In recent years, microsurgical and laparoscopic operations of ligation of dilated veins have been increasingly performed with varicocele, which significantly reduce the percentage of complications and relapses. In some cases, in children and adults, good results are achieved during X-ray endovascular occlusion of the testicular vein.
A good effect in the initial stages of varicocele in some cases can be achieved by eliminating stagnation in the pelvic organs. Patients are recommended to limit prolonged physical activity, normalize stools, exclude alcohol, take vitamins, lead a regular sex life, normalize the work and rest regime.