The abdominal wall and inguinoscrotal conditions
Spencer W. Beasley, John Hutson, Mark Stringer, Sebastian K. King, Warwick J. Teague in Paediatric Surgical Diagnosis, 2018
A varicocele is enlargement of the veins of the pampiniform plexus in the spermatic cord, and almost always involves the left side and develops around the time of puberty. There may be little abnormality to observe when the adolescent is supine apart from an asymmetrical scrotum (with the left side redundant), but on standing the veins fill and become visible, and feel like ‘a bag of worms’. A small secondary hydrocele may be observed. Varicoceles are usually symptomless, although some boys complain of a dragging ache or discomfort in the groin. If untreated, the left testis may not grow as much as the right testis at puberty, a reflection of the effect on spermatogenesis of unilateral warming of the testis by the surrounding veins. Uncommonly, a varicocele may develop from obstruction of one of the renal veins by a renal or perirenal tumour, of which Wilms tumour and neuroblastoma are the most common. Because the left testicular vein drains directly into the left renal vein, this sign is seen almost always on the left side. Consequently, an underlying cause must be suspected in a boy under 6 years of age who develops a varicocele; the tumour will usually be palpable as an abdominal mass.
Male infertility
C. Yan Cheng in Spermatogenesis, 2018
Varicoceles are diagnosed by physical exam. In standing position, grade 1 varicoceles can be palpated with Valsalva, grade 2 can be palpated even in the absence of Valsalva, and grade 3 can be visualized through the thin scrotal skin even in the absence of Valsalva. A varicocele that is palpable should become not palpable upon changing positions from standing to supine. In the event of an isolated right-sided varicocele, abdominal imaging, typically in the form of an ultrasound, is warranted to assess for an intra-abdominal mass causing venous compression. Furthermore, if physical exam is unclear, a scrotal ultrasound should be considered. Here, spermatic cord vein diameters should be measured both supine and standing, as well as assessment for reversal of blood flow. Vein diameters larger than 3 mm and reversal of flow are considered clinical varicoceles; veins smaller than 3 mm with reversal of flow are termed subclinical varicoceles.
Varicocele
Mark Davenport, James D. Geiger, Nigel J. Hall, Steven S. Rothenberg in Operative Pediatric Surgery, 2020
The management of varicocele remains highly variable in terms of surgical approach and methodology, but techniques include: Open inguinal or sub-inguinal surgery.Retroperitoneal laparoscopic selective ligation of the testicular vein(s) (Ivanissevich operation).Retroperitoneal mass ligation of vein(s), artery and lymphatics (Palomo operation).Antegrade sclerotherapy: A recent poll of UK pediatric urologists at the British Association of Paediatric Urologists (BAPU) 2018 Consensus Session indicated that 54% would recommend antegrade sclerotherapy for managing pediatric and adolescent varicocele.
Varicocele management for infertility and pain: A systematic review
Published in Arab Journal of Urology, 2018
Scott D. Lundy, Edmund S. Sabanegh
A varicocele is defined as a dilated pampiniform plexus, the network of small veins responsible for venous drainage from the testicle and deep tissues of the hemiscrotum. This plexus is contiguous with the ipsilateral gonadal vein, which drains into the renal vein on the left and directly into the inferior vena cava on the right. As a result, the left renal vein is typically 8–10 cm longer and has a higher hydrostatic pressure; this explains the discrepancy in incidence between the left side (which accounts for 90% of all varicoceles) and the right side, which if tense and unilateral may be concerning for malignancy [1]. Epidemiologically, varicoceles are common and occur in 15% of the general male population (Fig. 1 ) [2,3]. Varicoceles typically develop during puberty. A large population-based study showed a prevalence of 0.92% in boys aged between 2 and 10 years and a dramatic rise to 11% in boys aged 11–19 years [4]. Men presenting with infertility have an even higher prevalence, ranging from 35% for men presenting with primary infertility [5] to 45–81% for those presenting with secondary infertility [5,6].
The prevalence and severity of varicocele in adult population over the age of forty years old: a cross-sectional study
Published in The Aging Male, 2019
Huseyin Besiroglu, Alper Otunctemur, Murat Dursun, Emin Ozbek
Varicocele is an abnormal dilatation of internal spermatic veins within the pampiniform plexus. Varicoceles are a frequent scrotal finding in normal males. Although the pathogenesis and natural history remain controversial, varicocele is thought to contribute to the risk of infertility in men. Furthermore, two population-based studies indicate that 85% of men with varicocele have fathered children suggesting that its effect on paternity is less clear [1,2]. The underlying pathologic process is not well known, but varicoceles have been associated with turbulent venous flow related to the right angle insertion of the left testicular vein into the left renal vein, which could be an explanation why left-sided varicocele is observed more frequently. In addition, the nutcracker phenomenon, defined as the compression of the left renal vein between superior mesenteric artery and aorta, may contribute to the pathogenesis of varicocele [3,4].
Role of varicocele treatment in assisted reproductive technologies
Published in Arab Journal of Urology, 2018
Mehmet G. Sönmez, Ahmet H. Haliloğlu
Testicular varicocele is the abnormal expansion of the pampiniform plexus, which provides testicle venous drainage. It is the most common treatable cause of male infertility worldwide. It is detected in 40% of men with infertility and nearly 15% of adult men generally [1]. Varicocele may cause testicular atrophy, discomfort, infertility, and hypogonadism. Varicocele aetiology is not entirely clear, with venous reflux thought to be the main cause of varicocele-related testicular dysfunction [1,2]. There are three hypotheses for venous blood drainage impairment: (i) lack of or functional disorder in the venous valves, (ii) differences in the attachment of the testicular veins to the left renal vein and vena cava, and (iii) renal vein compression between the upper mesenteric artery and aorta (the ‘nutcracker’ effect) [2[3]–4]. Intratesticular temperature increase, testicle hypoxia, oxidant accumulation in the semen, renal and adrenal metabolite reflux, and anti-sperm antibodies may result in varicocele-related testicular dysfunction [5], and these are all a reflection of venous reflux effects. Varicocele may cause changes at the cellular level, which may induce testicular cell apoptosis and increase reactive oxygen species (ROS), decrease testicular DNA polymerase activity, change Sertoli cellular function, and decrease testosterone production by Leydig cells [6]. These, secondary to varicocele, can result in infertility.
Related Knowledge Centers
- Inguinal Canal
- Vein
- Scrotum
- Blood
- Blood Vessel
- Spermatic Cord
- Pampiniform Plexus
- Pelvic Compression Syndrome
- Testicle
- Male Infertility