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The male reproductive tract is responsible for the production, maturation, and transport of sperm. This tract is a complex and highly integrated entity. Sperm produced in the testicles are transported through the genital duct system and deposited in the urethra during ejaculation followed by emission.
Abnormalities within the male reproductive tract may present as a scrotal mass. Masses may have little or no health significance or may represent life-threatening illnesses. Therefore, it is necessary to follow a set course of action to determine the nature of the masse and the most appropriate treatment. For example, testicular cancer which can present as a scrotal mass, is a source of great concern and uniformly requires prompt intervention. Other masses, such as varicoceles, may be benign or cause testicular growth retardation in adolescent boys or impair fertility in adults. Thus, it is important for a patient to seek prompt medical attention when he identifies a scrotal mass or any lump or bump while performing a testicular self examination. The following information will assist you when talking to Dr. Shaw about varicoceles.
The spermatic cord is the structure that provides the blood supply to the testicle and contains the vas deferens which transports sperm from the testicle to the penis and urethra. The spermatic cord passes through the inguinal canal and continues into the scrotum. The pampiniform plexus is a group of interconnected veins, which drain the blood from the testicles and lies within the spermatic cord. The pampiniform plexus is believed to have an important functional role in maintaining testicular temperature in the appropriate range for sperm production. The pampiniform plexus cools blood in the testicular artery before it enters the testicles, helping to maintain an ideal testicular temperature, essential for optimal sperm production. Varicoceles are abnormal enlargements (dilations) of the pampiniform plexus of veins within the scrotum. They are similar to varicose veins of the leg, and often form during puberty. They can become larger and thus more noticeable with time. Left-sided varicocele are more common than right-sided varicocele, likely due to anatomical differences between the two sides. Ten to fifteen percent of boys have a varicocele. A fraction will develop testicular growth retardation during puberty.
Several causes of varicoceles have been suggested. Incompetent or absent valves within the spermatic veins may lead to pooling of blood from sluggish or even backflow. Additionally, the acute angle at which the left spermatic vein enters the renal (kidney) vein may transmit the relatively high pressure to result in backflow manifested in enlargement of the scrotal veins. This explains why varicoceles are more common on the left side since the gonadal vein on the left side enters the renal vein. The right gonadal vein is not as long and does not join with the right venal vein. Rarely, enlarged lymph nodes or other abnormal masses in the retroperitoneum (the space behind the abdominal cavity) will block the flow of blood in the spermatic veins, leading to acute enlargement of scrotal veins. This phenomenon is rare and is usually associated with pain. Significant injuries to the scrotum can also result in presentation or worsening of varicoceles.
Varicoceles are present in an estimated 15 percent of all men. It is not know how many lead to infertility but approximately 40 percent of men undergoing evaluation for infertility are found to have a varicocoele and decrease sperm motility. There is no association other anomalies, race, geographic or ethnic origin.
Some men diagnosed with a varicocele have no symptoms, but varicoceles are important for several reasons. Varicoceles are thought to cause infertility and testicular atrophy (shrinkage). Approximately 40 percent of cases of primary male infertility and 80 percent of cases of secondary male infertility are believed to be due to varicoceles. Varicoceles rarely cause pain. When pain is present, it can vary from a dull, heavy discomfort to a sharp pain. The associated symptoms may increase with sitting, standing or physical exertion – particularly if any one of these activities occurs over long periods of time. Symptoms often progress over the course of the day, and they are typically relieved when the patient lies on his back, allowing improved drainage of the veins of the pampiniform plexus.
Varicoceles can be discovered through self-examination or during routine physical examination. They may look or feel like a mass in the scrotum, and they have been described as having a “bag of worms” both because of their appearance and the way they feel. Physicians typically diagnose varicoceles with the patient in the standing position. The patient may be asked to take in a deep breath, hold it, and bear down while the physician feels the scrotum above the testicle. This technique, known as the Valsalva maneuver, assists the physician in detecting abnormal enlargement or increased fullness of the pampiniform plexus of veins. A physician may order a scrotal ultrasound test to help make the diagnosis, particularly if the physical examination is difficult or inconclusive. Radiographic hallmarks of varicoceles on scrotal ultrasonography are veins greater than three millimeters in size with reversal of blood flow within the veins of the pampiniform plexus during the Valsalva maneuver. In addition, the ultrasound study can provide testicular size measurements which is factored in the medical decision process in adolescents. However, routine radiographic screening for varicoceles in the absence of physical findings is not indicated.Smaller varicoceles (grade I) are not usually visible , but felt instead on exam. Large varicoceles (grades 2,3,4) can be noted by observation only and they typically result in decrease in testicular size.
Varicoceles are usually treated with surgery. There is also a procedure called percutaneous embolization, performed by a radiologist that can treated varicoceles by inserting agents to cause a blockage; however, embolizations have a high recurrence rate. If a patient is unable to undergo surgery, this may be a suitable option. We will focus on the two common surgeries here though, that involve ligation (obstruction) of the spermatic veins, thus interrupting blood flow in the vessels of the papiniform plexus.
Laparoscopic varicocele repair utilizes small (1cm) incisions in the abdominal wall, through which the instruments are inserted. The laparoscopic instruments are a camera, heated scissors, graspers, etcs. They are about the width of a pen. The camera inside the abdomen is used to visualize the surgery, and the surgeon uses these small instruments to operate. The gonadal vein is visualized in the abdomen; this is the vein that leads to the branching, dilated veins in the scrotum. Small clips are placed on the gonadal vein and it is cut.
Laparoscopic varicocelectomy is an outpatient procedure (you get to go home same day) performed under general anesthesia (you will be asleep). It allows for faster recovery and typically patients only have abdominal pain for 1-2 days. It is appropriate for smaller varicoceles (grade 1-2).
The open surgery is performed through a single 1 inch incision above the scrotum. This technique is appropriate for larger varicoceles (grades 3-4), because they have a lower chance of recurrence. In open varicocelectomy, the indentified. These large, varicosed veins are individually tied off and cut.
Open varicocelectomy is also an outpatient procedure, performed under general anesthesia. Because it is done above the scrotum, the recovery is somewhat longer than the laparoscopic approach. Typical side effects/risks can include scrotal bruising, swelling, pain, or hematoma formation. A hematoma is clotted blood in the scrotum and can feel like a painful hard mass. If uncomplicated, it will resolve on its own within a few weeks.
Recovery time after Laparoscopic surgical repair is rapid. Pain is usually mild, and patients are asked to avoid strenuous activity for 10 to 14 days. Office work can typically be done one to two days after surgery. A follow-up visit with the urologist is scheduled. A follow-up semen analysis is obtained three to four months later if the procedure was performed to treat associated infertility. Open procedures do have somewhat of a longer recovery time. It can take about 2-3 weeks for the swelling/bruising to decrease. We recommend scortal support (tight fitting underwear) and ice after open varicocelectomies. Complications resulting from either open or laparoscopic approaches are rare, but include varicocele persistence/recurrence, hydrocele formation and injury to the testicular artery leading to loss of the testis (fortunately, this is an extreme and rare complication).
Failure to treat a varicocele may result in testicular atrophy and/or a decline in semen quality. This may lead to infertility. The varicocele may, over time, lead to permanent, irreversible testicular injury. The decision is dependent on the severity of your varicocele as well as your future plans for children.
The use of adequate scrotal support (e.g., athletic supporter, briefs style underwear, etc.) can help the pain associated with a varicocele. Lying on your back facilitates varicocele drainage and often improves episodic discomfort as well. Use of analgesic agents (e.g., acetaminophen, ibuprofen, etc.) may be of benefit in treating the pain associated with a varicocele. Additionally, many patients obtain lasting relief of symptoms with varicocele correction through the above-mentioned techniques.
Semen analyses are typically obtained at three to four month intervals after the procedure. Improvement is often seen within six months, but may not be observed until one year postoperatively.
Indications for correction of a varicocele in an adolescent include disparity in testicular size exceeding 10% by volume. Additionally, correction is a consideration in patients with pain. Treatment of adolescents is highly individualized, and consultation with a urologist or a pediatric urologist to further discuss the appropriateness of treatment for a particular patient is highly recommended.