6. Varicocele Flashcards
(102 cards)
1
Q
Varicocele
A
- Definition
- Note
- Etiology
2
Q
Definition of Varicocele
A
Elongation, dilatation and tortuosity of the pampiniform plexus of veins or the cremasteric veins, Internal and external spermatic veins
3
Q
Note on Varicocele
A
The testicular vein has no valves & the pampiniform plexus has few inefficient valves
4
Q
Etiology of Varicocele
A
- Primary Varicocele
2. Secondary Varicocele
5
Q
Primary Varicocele in Etiology of Varicocele
A
- INCIDENCE
- AGE
- ETIOLOGY
- SIDE AFFECTED
- CLINICAL PICTURE
- COMPLICATIONS
- INVESTIGATIONS
- TREATMENT
6
Q
INCIDENCE of Primary Varicocele in Etiology of Varicocele
A
Its percent in males is about 20%
7
Q
AGE of Primary Varicocele in Etiology of Varicocele
A
usually affects young adults (15-30 years).
8
Q
ETIOLOGY of Primary Varicocele in Etiology of Varicocele
A
- Its exact cause is not known
- but may be due to congenital weakness of venous walls
- which may be due to familial weakness of mesenchymal tissue
- Associated with hernia, varicose veins, and flat feet
9
Q
SIDE AFFECTED in Primary Varicocele in Etiology of Varicocele
A
Primary Varicocele almost always affects the left side
10
Q
Pathogenesis of Left side affection in SIDE AFFECTED in Primary Varicocele in Etiology of Varicocele
A
- The right angled termination of the left spermatic vein into the left renal vein, impedes the venous return, in contrast to the oblique termination of the
right vein into the IVC. - The left renal vein passes anterior to the aorta & posterior to the superior mesenteric artery (nutcracker action).
- Ineffective anti-reflux valves at the junction of the testicular vein and renal vein
- The lower position of the left testes & the higher position of the left kidney
- Compression of the left testicular vein by the heavily loaded pelvic colon
11
Q
CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele
A
- Symptoms
* Examination
12
Q
Symptoms in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele
A
- Usually, the condition is asymptomatic.
- Dragging pain
- The patient may complain of infertility.
- Complications may be the 1st presentation
13
Q
Main symptom in Symptoms in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele
A
The condition is asymptomatic.
14
Q
Dragging pain in Symptoms in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele
A
- what Increase
- what Decrease
- Pathogenesis
15
Q
what Increase Dragging pain in Symptoms in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele
A
- prolonged standing
* hot weather
16
Q
what Decrease Dragging pain in Symptoms in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele
A
relieved by lying down and during sleep
17
Q
Pathogenesis of Dragging pain in Symptoms in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele
A
Due to over relaxation of cremasteric and dartos muscles to inc. heat loss as the venous congestion inc. temp
18
Q
Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele
A
- INSPECTION
- PALPATION
- Examine the abdomen to exclude 2ry varicocele.
- GRADING OF VARICOCELE
19
Q
INSPECTION in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele
A
- Large varicoceles are also visible.
2. The affected side of the scrotum hangs lower than normal.
20
Q
PALPATION in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele
A
- Scrotal neck test
- A bag of worms
- Differentiate between 1ry and 2ry varicocele
- Associated pathology
21
Q
Scrotal neck test in PALPATION in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele
A
- Normal Finding
* Abnormal Finding indicating Varicocele
22
Q
Normal Finding in Scrotal neck test in PALPATION in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele
A
Normally only the vas is felt
23
Q
Abnormal Finding indicating Varicocele in Scrotal neck test in PALPATION in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele
A
inguino-scrotal swelling giving a thrill on cough.
24
Q
A bag of worms in PALPATION in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele
A
On standing there are dilated, elongated & tortuous veins felt above the testis like “a bag of worms”.
25
Differentiate between 1ry and 2ry varicocele in PALPATION in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele
1. Primary varicocele empties
* while the patient is lying down and the scrotum is elevated
* by the bow test
2. Examine the abdomen to exclude 2ry varicocele.
26
Associated pathology in PALPATION in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele
There is often a small 2ry hydrocele.
27
GRADING OF VARICOCELE in Examination in CLINICAL PICTURE of Primary Varicocele in Etiology of Varicocele
* Grade 0 Varicocele detected by duplex only.
* Grade 1 Varicocele detected by straining.
* Grade 2 Varicocele detected by palpation.
* Grade 3 Varicocele detected by inspection
28
COMPLICATIONS of Primary Varicocele in Etiology of Varicocele
1. subfertility
2. Recurrent attacks of thrombophlebitis
3. 2ry vaginal hydrocele.
4. Anxiety neurosis
5. Testicular atrophy (rare)
29
Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele
* Incidence
* Pathology
* Etiology
30
Incidence of Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele
15%
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Pathology of Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele
asthenospermia mainly, then oligospermia
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Etiology of Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele
1. Thermal theory
2. Toxic theory
3. Hypoxic theory
4. Note
33
Thermal theory in Etiology of Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele
Warmth from venous congestion affects spermatogenesis
34
Toxic theory in Etiology of Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele
Metabolic substances of steroids & catecholamines are toxic and potentially spermatogenic inhibitors reach the left testicular vein at a higher levels.
35
Hypoxic theory in Etiology of Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele
Venous stasis causes hypoxia & lactic acidosis affecting spermatogenesis.
36
Note on Etiology of Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele
Subfertility occurs even if the condition is unilateral
37
The reason why Subfertility occurs even if the condition is unilateral in Note on Etiology of Subfertility in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele
due to presence of intercommunicating veins between both testicular veins in the abdomen.
38
Recurrent attacks of thrombophlebitis in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele
* Etiology
| * Clinical Picture
39
Etiology of Recurrent attacks of thrombophlebitis in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele
Due to Accumulation of metabolites
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Clinical Picture of Recurrent attacks of thrombophlebitis in COMPLICATIONS of Primary Varicocele in Etiology of Varicocele
Stitching pain
41
INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele
1. Semen analysis
2. Scrotal Duplex scan
3. Abdominal U/S
42
Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele
* Normal Findings
* Affected parameters
* Normal grading of motility as mentioned by WHO
* Note
43
Normal Findings in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele
Count 20 - 150 million /ml
44
Affected parameters in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele
Stress triad:
* Motility )> shaking motility
* Count
* increased the abnormal forms
45
Most prominent parameter in Affected parameters in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele
Motility )> shaking motility
46
Normal grading of motility as mentioned by WHO in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele
* Grade a ( fast progressive)
* Grade b ( slowly progressive)
* Grade c (non-progressive or local motility only)
* Grade d (immotile)
* Note
47
Grade a ( fast progressive) in Normal grading of motility as mentioned by WHO in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele
sperm are those which swim forward fast in a straight line-like guided missiles.
48
Grade b ( slowly progressive) in Normal grading of motility as mentioned by WHO in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele
sperm swim forward, but either in a curved or crooked line.
49
Grade c (non-progressive or local motility only) in Normal grading of motility as mentioned by WHO in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele
sperm move their tails only, but do not move forward.
50
Grade d (immotile) in Normal grading of motility as mentioned by WHO in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele
sperm do not move at all.
51
Note on Normal grading of motility as mentioned by WHO in Semen analysis in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele
ln order to give birth, grade (a + b) shoutd be at least 50% as sperms of grade (c & d) are considered poor.
52
Scrotal Duplex scan in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele
* Normal Findings
* Abnormal Findings
* Benefits
53
Normal Findings in Scrotal Duplex scan in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele
Normal diameter of the Spermatic veins
0.8 - 1.2 mm (1 mm)
54
Abnormal Findings in Scrotal Duplex scan in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele
1. Reversed blood flow in the Spermatic veins
| 2. Dilated Spermatic veins ( > 1.5 mm)
55
Benefits of Scrotal Duplex scan in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele
1. Detection of subclinical cases of contralateral side
2. Detection of Which vein is affected ( internal or external spermatic veins)
3. provides full assessment of the testis
4. Detects 2ry vaginal hydrocele if present
56
Abdominal U/S in INVESTIGATIONS of Primary Varicocele in Etiology of Varicocele
For older patients e.g : 40 years old
exclude causes of Secondary Varicocele
e.g. hypernephroma
57
TREATMENT of Primary Varicocele in Etiology of Varicocele
l- Conservative treatment
ll- Surgical treatment
58
Conservative treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
1. In early cases, the patient is reassured.
2. For pain, a scrotal support can be used especially in hot weather.
3. Advise the patient to take frequent cold baths.
4. Advise the patient to avoid sexual congestion & prolonged standing.
59
Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
* Indications
* Aim
* Operations & Approaches
60
Indications of Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
1. Subfertility: After complete exclusion of all other causes of infertility.
2. A large painful varicocele )> severe intolerable pain
3. Before admission to a military college
61
Aim of Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
Prevention of venous reflux from the left renal vein to the testicular vein is achieved by attacking the venous return of the testis
62
Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
1. Retroperitoneal approach
2. Inguinal approach
3. Scrotal approach
4. Recent trends
63
Retroperitoneal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
* Alternative name
* Principle
* Advantages
* Disadvantages
64
Alternative name for Retroperitoneal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
Palomo's operation
65
Principle of Retroperitoneal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
Ligation and division of the testicular vein (1 or 2) in the retroperitoneal space as it emerges from the internal ring
66
Advantages of Retroperitoneal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
No postoperative hydrocele
67
Disadvantages of Retroperitoneal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
Recurrence is common as the cremasteric vein is not ligated
68
Inguinal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
* Principle
* Advantages
* Disadvantages
69
Principle of Inguinal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
1. Ligation and division of the pampiniform plexus of veins together with the cremasteric vein in the inguinal canal
2. Excision of a segment of the vein to a avoid recanalization.
3. Eversion of the tunica vaginalis is better done routinely
70
Advantages of Inguinal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
Less incidence of recurrence as the cremasteric vein is ligated.
71
Disadvantages of Inguinal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
Postoperative hydrocele is common
72
The reason why Postoperative hydrocele is common in Disadvantages of Inguinal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
due to interruption of the lymphatic vessels so eversion of the tunica vaginalis is better done routinely
73
Scrotal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
* Indication
* Principle
* Advantages
* Disadvantages
74
Indication of Scrotal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
* Not recommended by all surgeons
| * Suitable for neurotic illiterate patients
75
Principle of Scrotal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
1. Ligation and division of the pampiniform plexus in the scrotum
2. Eversion of the tunica vaginalis is recommended routinely by some surgeons.
76
Advantages of Scrotal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
* Removal of the swelling & elevation of the testis
| * No recurrence as the cremasteric vein is ligated
77
Disadvantages of Scrotal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
* Here the testicular artery is an end artery with higher possibility of injury.
* Postoperative hydrocele is common
78
The reason why Postoperative hydrocele is common in Disadvantages of Scrotal approach in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
due to interruption of the lymphatic vessels so eversion of the tunica vaginalis is recommended routinely by some surgeons.
79
Recent trends in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
1. Laparoscopic varicocelectomy .
2. Testicular vein embolisation under radiological imaging.
3. Sub-inguinal microsurgical varicocelectomy
80
Sub-inguinal microsurgical varicocelectomy in Recent trends in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
* Alternative name
* Principle
* Advantages
* Note on postoperative outcome
81
Alternative name for Sub-inguinal microsurgical varicocelectomy in Recent trends in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
Marc Goldstein
82
Principle of Sub-inguinal microsurgical varicocelectomy in Recent trends in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
1. The varicocele is ligated at the neck of the scrotum just below the external ring.
2. This procedure employs a powerful operating microscope that provides 10.25 power magnification to the tiny 1 millimeter testicular artery.
83
Advantages of Sub-inguinal microsurgical varicocelectomy in Recent trends in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
1. Reliable identification and preservation of the testicular artery and lymphatic channels.
2. Reliable identification & Ligation of pampiniform plexus of veins & and cremasteric veins.
84
Note on postoperative outcome in Sub-inguinal microsurgical varicocelectomy in Recent trends in Operations & Approaches in Surgical treatment in TREATMENT of Primary Varicocele in Etiology of Varicocele
Postoperatively, venous return is via the vasal veins, which drain into the internal pudendal system and usually have competent valves
85
Secondary Varicocele in Etiology of Varicocele
* INCIDENCE
* ETIOLOGY
* CLINICAL FEATURES
* TREATMENT
86
INCIDENCE of Secondary Varicocele in Etiology of Varicocele
This is a rare condition
87
ETIOLOGY of Secondary Varicocele in Etiology of Varicocele
due to obstruction of the venous flow in the
spermatic vein by :
1. Iatrogenic cause
2. Hypernephroma
3. Abdominal or pelvic tumour.
4. Retroperitoneal fibrosis.
88
Iatrogenic cause in ETIOLOGY of Secondary Varicocele in Etiology of Varicocele
* actually the most common cause
| * During hernia surgery During narrowing of internal ring
89
Hypernephroma in ETIOLOGY of Secondary Varicocele in Etiology of Varicocele
* as the malignant cells form a malignant thrombus inside the renal vein
i. e. permeation of the renal vein
90
CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele
Difference between primary varicocele and Secondary varicocele
91
Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele
1. Age
2. Side
3. Course
4. Effect of Lying down or scrotum elevation
5. Abdominal Examination and U/S
6. Abdominal
92
Age of primary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele
usually affects young adults (15-30 years).
93
Age of Secondary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele
It occurs after the age of 40 years.
94
Side of primary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele
almost always affects the left side
95
Side of Secondary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele
It affects both sides equally
96
Course of primary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele
Prolonged course
97
Course of Secondary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele
It develops rapidly and enlarges in a few weeks
98
Effect of Lying down or scrotum elevation of primary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele
It disappears on lying down or when the scrotum is elevated
99
Effect of Lying down or scrotum elevation of Secondary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele
It does not disappear on lying down or when the scrotum is elevated
100
Abdominal Examination and U/S of primary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele
No abnormality detected
101
Abdominal Examination and U/S of Secondary varicocele in Difference between primary varicocele and Secondary varicocele in CLINICAL FEATURES of Secondary Varicocele in Etiology of Varicocele
1. Hypernephroma
2. Abdominal or pelvic tumour.
3. Retroperitoneal fibrosis.
102
Treatment of Secondary Varicocele in Etiology of Varicocele
Treatment of the cause
