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3. VARICOCE
LEBY
ABDELRAHMAN M ABDELKADER

4. Definition
Epidemiology
Etiology
Pathophysiology
Diagnosis
investigation
Treatment
Complication
Reference

5. Definition:
Varicocele means abnormal dilatation, elongation & Tortuosity

6. Epidemiology:
• It is unusual in boys under the age of 10 years.
Incidence increases after puberty.
• It is generally reported that varicoceles are
present in 15% of the general male population, in
35% of men with primary infertility, and in up to
80% of men with secondary infertility.

7. Secondary
Abdominal mass
Retroperitoneal fibrosis
-Liver cirrhosis
Primary or
idiopathic
Due to valve
pathology either
weakness or
complete loss
98% lt side
Etiology:

8. Why left varicoele is common???
1-the length of the left testicular vein
2-the angle of insertion
3-The "nutcracker phenomenon“
4-the postion or arrangement of veins
5- their postion in scrotum no supporting structure (loose
tissue)

9. pathophysiology hyperthermia
Hypoxia
Endocrine imbalance
Reflux metabolite
Increased NO
Abnormal arterial flow
Antisperm antibody

10. Diagnosis:
History
• It is usually asymptomatic (between 2% and 10% have symptoms) and only
rarely causes pain.
• Patient often describes as feeling 'like a bag of worms'.
• Patients may report scrotal heaviness.
It may be an incidental finding, being discovered at routine medical
examinations or noticed in children by parents.
• Infertility investigations.

11. EXAMINATION
 Careful examination, with the patient standing, is the most important method of
detection:
 The scrotum on the side of the varicocele hangs lower than on the normal side.
 Dilation and tortuosity of the veins increase with standing and usually decrease on
lying down. The varicocele cannot usually be palpated with the patient lying down.
 Performing the Valsalva maneuver whilst standing increases the dilation.
 There may be a cough impulse..
 They vary in size and may be classified as:
 Large. Easily identified by inspection alone. Sometimes called grade III.
 Moderate. Identified by palpation but without performing the Valsalva manoeuvre.
Grade II.
 Small. Identified only by 'bearing down' to increase intra-abdominal pressure
(impedes varicocele drainage) and increase the size of varicocele. Grade I.

12. Investigation
1- semen analysis
2-color Doppler
3-abdominal ultrasound
4-Venography
5-Radio nucleotide angiography

13.  Varicocele treatment should be offered to the male partner of a couple attempting to
conceive, when all of the following are present: 1) a varicocele is palpable; 2) the couple
has documented infertility; 3) the female has normal fertility or potentially correctable
infertility; and 4) the male partner has one or more abnormal semen parameters or
sperm function test results.
 Adult men who have a palpable varicocele and abnormal semen analyses but are not
currently attempting to conceive should also be offered varicocele repair.
 Young men who have a varicocele and normal semen analyses should be followed with
semen analyses every one to two years.
 Adolescents who have a varicocele and objective evidence of reduced ipsilateral testicular
size should be offered varicocele repair. Adolescents who have a varicocele but normal
ipsilateral testicular size should be offered followup monitoring with annual objective
measurements of testicular size and/or semen analyses.
American urology association guide lines recommendation:

15. Approaches to surgery include[19]:
•Inguinal
•Retroperitoneal
•Infra-inguinal or subinguinal
•Laparoscopic
•Microscopic

16. Complication
1.wound infection
2.hydrocele,
3.persistence Of varicocele
4.recurrence of varicocele
5.Rarely testicular atrophy.

17. REFERENCES.
1- Lee J, Binsaleh S, Lo kC et al, Varicocelectomy may benefit men with a Sertoli cell-only
pattern on microsurgical testicular sperm extraction: a case report. Urology.2008,71:1226- 1227
2- Schlegel PN, Kaufmann J, Role of varicocelectomy in men with nonobstructive azospermia.
Ferti Steril. 2004;81:1585-1588.
3- Hppps CV, Goldstein M, S patient hlegel PN. The diagnosis and treatmentof azospermia in
the age of intracytoplasmic sperm injection. Urol Clin North Am. 2002;29: 891-911.
4- Zampieri N, Bosaro L, Costantini C, et al, Relationship between testicular sperm extraction
and varicocelectomy in patients with varicocele and nonobstructive azoospermia. Urolo,
2003,81 (1),74-77
5- Urkish children and adoAkbay E, Cayan S, Doruk E, et al: the prevalence of varicocele and
varicocele-related testicular atrophy in children and adolescent. BJU Int 2000;86:490
6- Gorelick JL, Goldstein M: Loss of fertility in men with varicocele. Ferti Steril 1993;59:613-6
7- Smith JF, Walsh TJ, Shindel AW, et al: Sexual, marital, and social impact on man's
perceived infertility diagnosis. J Sex Med 2009;6(9):2505

18. 8. Paduch DA, Niedzielski J. Repair versus observation in adolescent varicocele: a prospective
study. J Urol 1997 Sep;158(3 Pt 2):1128-1132.
9.Yamamoto M, Hibi H, Katsuno S, and Miyake K. Effects of varicocelectomy on testis volume and
semen parameters in adolescents: a randomized prospective study. Nagoya J Med Sci 1995;
58:127132
10.Nagler HM, Luntz RK, Martinis FG. Varicocele. In: Infertility In The Male. Edited by Lipshultz LI
and Howards SS, St. Louis:Mosby Year Book, 1997, p. 336-359
11. Gorelick J, Goldstein M. Loss of fertility in men with varicocele. Fertil Steril 1993;59(3):613-
616.
12.Kim ED, Leibman BB, Grinblat DM and Lipshultz LI. Varicocele repair improves semen
parameters in azoospermic men with spermatogenic failure. J Urol 1999; 162: 737-740
13.Schlesinger MM, Wilets IF and Nagler HM. Treatment outcomes after varicocelectomy. A critical
analysis. Urol Clin N America 1994; 21: 517-529
14.Goldstein M. Surgical management of male infertility. In:
Wein A, Kavoussi LR, Novick AC, Partin AW, Peters C,editors. Campbell’s urology. Vol 1. 10th ed.
Philadelphia: WB Saunders, Co; 2011;648–87.
15.Cho SY, Kim TB, Ku JH, Paick JS, Kim SW. Beneficial effects of microsurgical varicocelectomy
on semen parameters in patients who underwent surgery for causes other than infertility. Urology
2011;77:1107-10.