Varicocele Flashcards
what is the definition of varicocele?
A varicocele is the abnormal dilation of the internal spermatic veins and pampiniform plexus that drain blood from the testis.
what is the epidemiology of varicocele?
Between 10% and 15% of men and adolescent boys in the general population have varicocele
Pre-pubertal varicoceles are very rare, suggesting that puberty may be one initiating factor
what is the aetiology of varicocele?
Anatomical features, namely increased hydrostatic pressure in the left renal vein and incompetent or congenitally absent valves, are typically implicated as the primary causes of varicocele formation.
They are most commonly thought to be caused by incompetent valves within the left internal spermatic vein. In addition, the left pampiniform plexus is subjected to increased hydrostatic pressures due to the right-angle insertion of the vein into the left renal vein. The left internal spermatic vein inserts into the left renal vein at a right angle, as opposed to the right internal spermatic vein, which joins the inferior vena cava at an oblique angle. In addition, the left internal spermatic vein is 8 to 10 cm longer, resulting in increased hydrostatic pressure transmission. Furthermore, a ‘nutcracker’ phenomenon may exist as the left renal vein traverses under the superior mesenteric artery. However, despite these differences, varicoceles have been demonstrated in males with competent valves as well. It is clear that varicocele formation cannot be explained by a single theory and results from a combination of the above anatomical factors.
Rarely, varicocele can be caused by a retroperitoneal or abdominal compressive mass. This could cause a varicocele that does not diminish in the supine position or an isolated right-sided varicocele.
what are the risk factors for varicocele?
Somatometric parameters (tall with low BMI) Family history
what is the pathophysiology of varicocele?
Clinically detectable varicoceles can be associated with abnormal gonadotropin levels, impaired spermatogenesis, histological changes to sperm, and infertility. The exact cause is not known, but most believe that a major contributor is thermal damage secondary to an impaired countercurrent mechanism that normally keeps intrascrotal temperatures 1°C to 2°C (2°F to 4°F) lower than normal body temperature. Other theories cite inadequate elimination of reactive oxygen species due to impede venous out-flow, impaired arterial in-flow resulting in hypoxia, and reflux of toxic adrenal and renal metabolites as causative factors.
what are the key presentations of varicocele?
Risk factors
Painless scrotal mass
Left sided signs and symptoms
Small testicle
what are the signs of varicocele?
Infertility Aged over 12 Risk factors Painless scrotal mass Left sided signs and symptoms Small testicle
what are the symptoms of varicocele?
Scrotal or groin pain
what are the first line and gold standard investigations for varicocele?
Clinical diagnosis - Physical examination is the primary diagnostic test for varicoceles. Palpation and/or inspection of the spermatic cord above the testicle may reveal the pathognomonic ‘bag of worms’ appearance. The Valsalva manoeuvre may be necessary to elicit small varicoceles (grade I/II).
what other tests could be done for varicocele?
Ultrasound, serum FSH, testosterone, DFI
what are the differential diagnoses for varicocele?
Paratesticular mass, cord hydrocele, inguinal hernia, spermatocele
how is varicocele managed?
Reassurance, observation, surgery
how is varicocele monitored?
In adolescents, serial examinations must be done yearly until testicular growth is complete. For patients undergoing surgery, following repair, the patient should be examined at 1 month and then at 6- and 12- to 18-month intervals.
what are the complications of varicocele?
Post surgical coil migration, post surgical hydrocele, post surgical varicocele recurrence
what is the prognosis of varicocele?
Varicocele treatment will fully eliminate more than 90% of varicoceles (98% if microscopic subinguinal approach is used). The recurrence rate varies depending on surgical technique, as does the complication rate.
