Varicocele

1. VARICOCELE
Ratheesh.R
SLMGNC

2. NORMAL ANATOMYOF
PAMPINIFORM PLEXUS
 Union of multiple spermatic veins from back of testis
and epididymis.
 Ascend along cord infront of the ductus deferens
below the superficial inguinal ring.They unite to form
3-4 veins--inguinal canal—enter abdomen through
deep ring--forms 2 veins which unite—testicular
vein.
 Drain from testes, epididymis and vas deferens-drain
into spermatic veins
 Left spermatic vein drains into renal vein and right
spermatic into inferior vena cava and then into the
rightt renal vein.

3. NORMAL ANATOMY

4. What is varicocele?
 Dilatation and tortuosity of the pampiniform
plexus and so also of the testicular veins.
 Seen commonly in men aged 15-30yrs and
rarely after 40yrs.
 Occur in 15-20% of all males and 40% of all
infertile males.
 Normal small vessels of plexus- 0.5-1.5mm.
Diameter greater than 2mm - Varicocele.

5.  Seen commonly on the left side –5 reasons.
-longer
-enters at right angle to the renal vein
-left testicular artery arching over it
-a loaded sigmoid colon.
- compressed b/w the aorta and SMA.

6. GRADING
 SMALL - identified only by bearing
down i.e, an increase in abdominal pressure.
 MODERATE - identified by palpation w/o
bearing down.
 LARGE - easily identifed by inspection
alone.
 SEVERELY TORTUOUS.

7. Aetiology and types
 1.IDIOPATHIC/PRIMARY – due to
incompetency of valves. 98% occur on the left
side.
 2.SECONDARY- pelvic or abdominal mass.
- L renal cell carcinoma with
tumor thrombus in left vein.
-Nutcracker syndrome- SMA
compressing left vein. Common conditions-
Retroperitoneal fibrosis or adhesions.

8. CLINICAL FEATURES
 Swelling
 Dragging /aching pain in the groin and
scrotum
 “ Bag of worms” feeling
 Scrotum on the affected side hangs down.
 On lying down, it gets reduced.
 Bow sign- hold varicocele b/w thumb and
fingers, patient is asked to bow-reduced in
size.

9.  Cough impulse present
 Long standing cases- affected side testis is
reduced in size and softer.
 Fertility problems.

10. Varicocele and subfertility
 Altered heat exchange mechanism due to
stagnation- hyperthermia-inhibition of
spermatogenesis.
 Increased temperature-increased metabolic
activity-depletion of glycogen storage-injury
of parenchyma of testis-oligospermia.
 Hypoxia, cell dysfunction-low testosterone.
 Maturation arrest-poor spermatogenesis.

11. INVESTIGATIONS
 Venous doppler of the scrotum and groin-
-standing/ valsalva’s manouevre.
 USG abdomen to look for kidney tumours.
 Semen analysis

13. INDICATIONS FOR SURGERY
 American Urological Society recommends that
varicocele treatment should be offered to the
male partner of a couple attempting to
conceive when all of the following are present.
 A varicocele is palpable.
 The couple has documented infertility.
 The female has normal fertility or potentially
correctable infertility.
 The male partner has one or more abnormal
semen parameters or sperm function test
results.

14.  The indications in adolescents- presence of
significant testicular asymmetry (>20%)
demonstrated on serial examinations, testicular
pain, and abnormal semen analysis results.
Very large varicoceles may also be repaired;
however, in the absence of atrophy, this
indication is relative and controversial .

15. TREATMENT
 3 SURGICAL AND 1 NON SURGICAL
PROCEDURE.
1. VARICOCELECTOMY-
The most common approaches are
 inguinal (groin)-easier and safer.
 retroperitoneal (abdominal)
 infrainguinal/subinguinal (below the groin),
 suprainguinal extraperitonial( Palomo’s operation),
 Scrotal approach- grade 4.

16.  2-3 inch incision.
 Ligate the offending
veins.
 Avoid strenuous
exercise for several
days after surgery.
 Apply scrotal
support.

17. Complications
 20% chance of recurrence.
 5% chance of hydrocele
 Damage to testicular artery.
 Infection.
 Hematoma

18. 2. MICRODISSECTION
 Microsurgery (also called microsurgical ligation)
smaller incision is made.
 Cut the skin and fatty tissue. Because muscle is not
cut-less pain and faster recovery.
 The doctor identifies the varicoceles (swollen veins)
through an operating microscope. Large varicoceles
are cut and stapled closed. Smaller varicoceles are cut
and stitched shut.
 Takes less than an hour and recovery time is short.
 Higher success rate, few complications, smaller scar.

19. 3.LAPROSCOPY
 Similar to conventional surgery. Incision made
on abdomen.
 High ligations required.
 Larger incision or more retraction needed.
 Complications more- testicular artery injury
and hydrocele.

20. 4. Coil Embolization, Radiologic
Balloon Occlusion or Radiologic
Ablation:
 Non-surgical procedure.
 Steel coil or silicone balloon catheter is
introduced into a vein below the groin through
a nick in the skin.
 Passed under X-ray guidance.
 Tiny metal coils or other embolizing agents
introduced through the catheter.

21.  No stitches needed.
 Patient can go back in 24hrs.
 Lower rates of complications.
 Disadv- less effective, higher recurrence(5-
11%), danger that the coil could migrate to the
heart and cause death .

24. CONTRAINDICATIONS
 Subclinical varicocele in an infertile person-
controversial.
 Discovery of a varicocele at the time of
vasectomy or vasectomy reversal-relative
contraindication to immediate repair.
 A 6-month delayed repair is recommended -to
allow the development of collateral vessels to
decrease the chance of vascular compromise to
the testicle.