Varicocele

Background

Varicocele dilatation of the pampiniform venous plexus Occurs approximately 15-20% of all males and in 2141% of infertile males
Disruption of internal spermatic veins blood flow return Dilatation of pampiniform venous plexus VARICOCELE

Valvular incompetence

(Medscape from webMD)

Etiology

80-90% in the left side because of several anatomic factors:

Left testicularis vein is longer than the right The angle at which the left testicularis vein enters the left renal vein The lack of effective anti reflux valves at the juncture of the testicular vein and renal vein The increased renal vein pressure due to its compression between the superior mesenteric artery and the aorta (Medscape from webMD)

Etiology

If there is a right side varicocele / bilateral varicoceles should suspected:

Retroperitoneal space abnormalites (vein obstruction due to tumor or thrombus) Congenital anomaly: Right testicularis vein enters the right renal vein

Predisposition Factors

Increases abdominal pressure Trauma Injury Failure of organs:

Heart Liver Renal

Pathophysiology

Varicoceles can disrupt the spermatogenesis process in several ways:

Blood flow stagnation in testicular sirculation O2 supply to the testicles testicles hypoxia Renals and adrenals metabolite (catecolamin and prostaglandin) reflux through the internal spermatic vein to the testicles intratesticular temperature The presence of anastomosis between the left and right pampiniform venous plexus enabled the metabolite material streamed from the left testicles to right testicles impaired right testicular spermatogenesis

Presentation

Usually asymptomatic, Often seeks an evaluation for infertility or feel pain and heavy

Scrotal Examination

Performed in a standing position inspection and palpation of the scrotal If needed patients were asked to strain (valsava manouver) An obvious varicocele often described as feeling like a bag of worms

Scrotal Examination

Clinically varicoceles can be classified into the following 3 groups:

Grade I palpable only with valsava maneuver which increases intraabdominal pressure, thus impeding drainage and increasing varicole size Grade II palpable without need of valsava maneuver Grade III easily identified by inspection alone

Scrotal Examination

Testicles compared both the testis

Size width, length, and the volume (using orchidometer) Consistency

In some conditions the testicles are soft and small indicates the damage of the germinal cell

Imaging Studies

Using an ultrasound with color Doppler Indication: for clinically unpalpable varicocele but therere another signs that indicates varicocele (subclinical varicocele) Can detect blood flow in pampiniform plexus

Semen Analysis

To measure how far the varicocele caused the damage to the seminiferous tubule McLeod semen analysis result shows the stress pattern:

sperm motility the amount of immature sperm Morphology abnormalities

Surgical Therapy

Indications:

Palpable varicocele Symptomatic varicocele Bilateral varicocele Ipsilateral testicular atrophy Abnormal semen parameters Injury of scrotum Hydrocele Coagulation disorder Failure of organs:

Contraindications:

Renal Liver

- Heart

Surgical Therapy

The 3 most common surgical approaches:

Inguinal approache Retroperitoneal approache Subinguinal approache

All abnormal veins are tied permanently to prevent continued abnormal blood flow

Surgical Therapy

Goal:

Relieving significant testicular discomfort/pain not responsive to routine symptomatic treatment Reducing testicular atrophy (vol < 20ml, length < 4cm) Preservation of arterial flow to the testis

Postoperative

Rest for 2 days Outer dressings are removed 48 hours after surgery. Small strips of tape are left in place for 7-10 days Permitted bathing/showering for 48hours after surgery Diet starts with fluids and gradually return to solid food Prescribe pain medication Patients can engage in normal, nonstraining activity when they feel up to it

If activity causes discomfort should be discontinued Patients can resume more strenuous activities (eg, weightlifting, jogging) after 2 weeks

Refrain from intercourse for 1 week

Evaluation

The increased of testicular volume Improvement of semen analysiss result (every 3 month)

May take up to 3-4 months 66-70% patients have improved bulk semen parameters 40-60% patients have increased conception rates (Medscape from webMD)

Conception

Complications

Hydrocele in 2-5% patients Recurrent rates of varicocele as high as 10% Injury to the testicular artery in 0.9% of microsurgical varicocele repair

(Medscape from webMD)

References

Diunduh dari : http://emedicine.medscape.com/article/438591overview http://www.maleinfertility.org/new-varicocele.html Dasar2 urologi edisi 3 Basuki Blueprints urology Ch.4 Male Infertility