A varicocele is an abnormal enlargement of the
pampiniform venous plexus
The pampiniform plexus () is a venous plexus – a network of many small veins found in the human male spermatic cord, and the suspensory ligament of the ovary. In the male, it is formed by the union of multiple testicular veins from the back of ...
in the
scrotum
In most terrestrial mammals, the scrotum (: scrotums or scrota; possibly from Latin ''scortum'', meaning "hide" or "skin") or scrotal sac is a part of the external male genitalia located at the base of the penis. It consists of a sac of skin ...
; in a woman, it is an abnormal painful swelling to the
embryologically identical pampiniform venous plexus; it is more commonly called
pelvic compression syndrome
Pelvic compression syndrome is characterized by intermittent or persisting pain in the abdomen, which is exacerbated by abdominal pressure. A swelling of the veins in the valveless pampiniform plexus causes it.
Pathophysiology
While varicocele ...
. In the male varicocele, this plexus of
vein
Veins () are blood vessels in the circulatory system of humans and most other animals that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are those of the pulmonary and feta ...
s drains
blood
Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells.
Blood is com ...
from the
testicle
A testicle or testis ( testes) is the gonad in all male bilaterians, including humans, and is Homology (biology), homologous to the ovary in females. Its primary functions are the production of sperm and the secretion of Androgen, androgens, p ...
s back to the heart. The
vessels originate in the abdomen and course down through the
inguinal canal
The inguinal canal is a passage in the anterior abdominal wall on each side of the body (one on each side of the midline), which in males, convey the spermatic cords and in females, the round ligament of the uterus. The inguinal canals are lar ...
as part of the
spermatic cord
The spermatic cord is the cord-like structure in males formed by the vas deferens (''ductus deferens'') and surrounding tissue that runs from the deep inguinal ring down to each testicle. Its serosal covering, the tunica vaginalis, is an exten ...
on their way to the
testis
A testicle or testis ( testes) is the gonad in all male bilaterians, including humans, and is Homology (biology), homologous to the ovary in females. Its primary functions are the production of sperm and the secretion of Androgen, androgens, p ...
. Varicoceles occur in around 15% to 20% of all men.
[ The incidence of varicocele increase with age.
]
Signs and symptoms
Varicocele might be noticed as soft lumps, usually above the testicle and mostly on the left side of the scrotum.[ Right-sided and bilateral varicoceles also occur. Men with varicocele can feel symptoms of pain or heaviness in their scrotum.] Large varicoceles present as plexus of veins and may be described as a "bag of worms". Varicocele is sometimes discovered when investigating the cause of male infertility
Male infertility refers to a sexually mature male's inability to impregnate a fertile female. Male infertility can wholly or partially account for 40% of infertility among couples who are trying to have children. "A problem with the male is the s ...
.[
]
Cause
There are three main theories as to the anatomical cause; the first has to do with the geometry of the veins, wherein the vein on the left side connects to the larger outflowing vein at a right angle, which tends to fail; the second is that testicular valves that are supposed to prevent backflow fail (venous insufficiency) leading to swelling and compression of the valveless pampiniform plexus
The pampiniform plexus () is a venous plexus – a network of many small veins found in the human male spermatic cord, and the suspensory ligament of the ovary. In the male, it is formed by the union of multiple testicular veins from the back o ...
; the third is due to excessive pressure in upstream veins, created by nutcracker syndrome
The nutcracker syndrome (NCS) results most commonly from the compression of the left renal vein (LRV) between the abdominal aorta (AA) and superior mesenteric artery (SMA), although other variants exist. The name derives from the fact that, in ...
.
Pathophysiology
Often, the greatest concern concerning varicocele is its effect on male fertility. The relationship between varicocele and infertility is unclear. Some men with the condition are fertile, some have sperm that are normal in shape and move normally but are compromised in function, and some have sperm with abnormal shapes or that do not move well.[ Theories as to how varicocele affects sperm function include damage via excess heat caused by the blood pooling and ]oxidative stress
Oxidative stress reflects an imbalance between the systemic manifestation of reactive oxygen species and a biological system's ability to readily detoxify the reactive intermediates or to repair the resulting damage. Disturbances in the normal ...
on sperm.[
]Tobacco smoking
Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or released from the mouth, as is generally done with pipes and cigars. The practice is believed to hav ...
and mutations in the gene expressing glutathione S-transferase Mu 1
Glutathione ''S''-transferase Mu 1 (gene name GSTM1) is a human glutathione ''S''-transferase.
Function
Cytosolic and membrane-bound forms of glutathione ''S''-transferase are encoded by two distinct supergene families. At present, eight dis ...
both put men at risk for infertility; these factors may also exacerbate the risk that varicocele will affect fertility.[
]
Diagnosis
Following discovery of the sign of swelling comprising a mass, varicocele can be confirmed with scrotal ultrasound
Scrotal (or transscrotal) ultrasound is a medical ultrasound examination of the scrotum. It is used in the evaluation of testicular pain, and can help identify solid masses.
Indications
Although the development of new imaging modalities such as c ...
, which will show dilation of the vessels of the pampiniform plexus to be greater than 2.3 mm.
File:trans varicocele.tif, Varicocele in ultrasound (left: testicle)
File:Varicocele.png, Varicocele
Criteria
A universally accepted system for categorizing varicoceles does not exist, but according to the classification criteria established in 1970 by Dubin and Amelar, most commonly varicoceles are clinically assessed and categorized into three grades as follows:
# Grade 1 Varicocele: Characterized by the palpability of the varicocele only when the individual is in a standing position during the Valsalva maneuver
The Valsalva maneuver is performed by a forceful attempt of exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut while expelling air, as if blowing up a balloon. Variations of the maneuver can be ...
.
# Grade 2 Varicocele: The varicocele is palpable not only during the Valsalva maneuver but also at rest while standing.
# Grade 3 Varicocele: The most severe grade, where the varicocele is not only palpable but also visible through the scrotal skin, without any additional maneuvers.
In the Sarteschi (1993) classification system, varicoceles are categorized into five grades:
# Grade I: Reflux occurs solely at the groin level during the Valsalva maneuver, without evident scrotal deformation or testicular atrophy.
# Grade II: Reflux is limited to the proximal segment of the pampiniform plexus during the Valsalva maneuver, without scrotal deformation or testicular atrophy.
# Grade III: Reflux occurs in the distal vessels located at the lower scrotum exclusively during the Valsalva maneuver, and there is no scrotal deformation or testicular atrophy.
# Grade IV: Spontaneous reverse blood flow is present and intensifies during the Valsalva maneuver, resulting in scrotal deformation and the potential for testicular atrophy.
# Grade V: Resting reflux is evident within the dilated pampiniform plexus, possibly escalating during the Valsalva maneuver, and is consistently accompanied by testicular atrophy.
Imaging
Manual examination of the scrotum is required for proper interpretation of ultrasound images. During ultrasound examination, the diameters of the veins in the pampiniform plexus are measured, and regurgitation is measured. The subject is then instructed to stand up and Valsalva maneuver
The Valsalva maneuver is performed by a forceful attempt of exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut while expelling air, as if blowing up a balloon. Variations of the maneuver can be ...
is performed. The diameter is then measured, and changes in blood flow direction are recorded to assess for regurgitation.
Treatment
The most common surgical approaches are retroperitoneal
The retroperitoneal space (retroperitoneum) is the anatomical space (sometimes a potential space) behind (''retro'') the peritoneum. It has no specific delineating anatomical structures. Organs are retroperitoneal if they have peritoneum on thei ...
(abdominal using laparoscopic surgery
Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medli ...
), infrainguinal/subinguinal (below the groin), and inguinal (groin using percutaneous
{{More citations needed, date=January 2021
In surgery, a percutaneous procedurei.e. Granger et al., 2012 is any medical procedure or method where access to inner organs or other tissue is done via needle-puncture of the skin, rather than by using ...
embolization
Embolization refers to the passage and lodging of an embolus within the bloodstream. It may be of natural origin ( pathological), in which sense it is also called embolism, for example a pulmonary embolism; or it may be artificially induced ...
).[
Possible complications of this procedure include ]hematoma
A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillaries. A hematoma is ...
(bleeding into tissues), hydrocele
A hydrocele is an accumulation of serous fluid in a body cavity. A hydrocele testis, the most common form of hydrocele, is the accumulation of fluids around a testicle. It is often caused by fluid collecting within a layer wrapped around the tes ...
(accumulation of fluid around the affected testicle), infection
An infection is the invasion of tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmis ...
, or injury to the scrotal tissue or structures. In addition, injury to the artery that supplies the testicle may occur, resulting in a loss of a testicle.[
Many people have reported post-operative pain after varicocele embolizations, which could be linked to metal sensitivities, nerve irritation in nearby tissue, or related complications. Scientific inquiry suggests that varicocele coil removal can resolve chronic pain post-embolization.
]
Prognosis
Whether having varicocele surgery or embolization improves male fertility is controversial, as good clinical data is lacking.[ There is tentative evidence that varicocelectomy may improve fertility in those with obvious findings and abnormal sperm;][ however, this has a ]number needed to treat
The number needed to treat (NNT) or number needed to treat for an additional beneficial outcome (NNTB) is an epidemiology, epidemiological measure used in communicating the effectiveness of a health-care intervention, typically a treatment with me ...
of 7 for varicocelectomy and 17 for embolization. There are also studies showing that the regular surgery has no significant effect on infertility. A 2012 Cochrane review
Cochrane is a British international charitable organisation formed to synthesize medical research findings to facilitate evidence-based choices about health interventions involving health professionals, patients and policy makers. It includes ...
(updated in 2021) found tentative but unclear evidence of improved fertility among males treated for varicocele. Evidence for sclerotherapy
Sclerotherapy (the word reflects the Greek ''skleros'', meaning ''hard'')
is a procedure used to treat blood vessel malformations ( vascular malformations) and also malformations of the lymphatic system. A medication is injected into the vessels ...
is unclear as of 2015.
Epidemiology
Around 15% to 20% of all adult males, up to 35% to 40% of men who are evaluated for male infertility, and around 80% of men who are infertile due to some other cause, have varicocele.[
]
See also
*
References
External links
Video of a microsurgical repair of grade 3 left varicocele
{{Authority control
Andrology
Male genital disorders
Scrotum
Vascular diseases