Varicocele of the Testis

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Varicocele: Definition and Classification

A varicocele is defined as ectatic and tortuous veins of the pampiniform plexus of the spermatic cord. Varicoceles are found in 15% of the male adolescents and may cause pain, damage to the testes and infertility.

Classification of Varicoceles

• Subclinical: no evidence of a varicocele with inspection or palpation, but positive scrotal thermography or Doppler reflux detection.
• Grade I: not visible, palpable only with a Valsalva maneuver.
• Grade II: not visible, palpable without a Valsalva maneuver.
• Grade III: visible through the scrotum without a Valsalva maneuver

Etiology of Varicocele

Primary Varicoceles

The nearly perpendicular configuration of the renal vein with the left internal spermatic vein combined with incompetent venous valves leads to a long blood column with high pressure. The distal internal spermatic vein and pampiniform plexus become ectatic and further venous valves decompensate. The different configuration of the right internal spermatic vein with the vena cava prevents the reflux of blood and varicocele formation.

Two types of varicocele can be differentiated:

• Pressure type: retrograde filling of the internal spermatic vein leads to varicocele formation, with no collaterals to the internal or external iliac vein.
• Shunt type: severe retrograde filling leads to the formation of a large varicocele with formation of collaterals to the internal or external iliac vein,

According to Dubin and Amelar (1970), varicoceles grade I are associated with the pressure type, varicoceles grade II and III are associated with the shunt type.

Secondary Varicocele

A retroperitoneal mass results in a flow impediment in the internal spermatic vein, which leads to a secondary varicocele.

Pathophysiology of the Testicular Dysfunction

Reflux of (Adrenal) Blood

Reflux of adrenal blood leads to the increase of norepinephrine in the varicocele and – by diffusion – in the testicular artery. This leads to a vasoconstriction in the testes.

Increased Testicular Temperature

Increased venous reflux of warm blood from the core of the body increases the temperature of the testis.

Elevated Venous Pressure

Venous reflux leads to an elevated venous pressure leading to a temperature increase and impairment of the testicular blood supply.

Dysfunction of the Testis

Reflux of adrenal metabolites, elevated testicular temperature, disturbed testicular perfusion and elevated venous pressure causes a dysfunction of the germinal epithelium. Signs are a microscopically visible impairment of the Sertoli cell function, decreased inhibin secretion and increased FSH concentration. The impairment of the testicular perfusion also affects the Leydig cell function with increased LH and normal to subnormal testosterone in patients with varicoceles. Abnormal hormone concentrations are often corrected with surgical therapy.

Testicular Pathology due to varicocele

Gross Pathology:

Higher grade varicoceles lead to an atrophy of the testes.

Microscopic Pathology:

• Reduction of spermatogenesis. Maturation arrest. In exceptional cases, Sertoli cell-only syndrome
• Leydig cell dysfunction
• Tubular thickening
• Interstitial fibrosis

Signs and Symptoms of a Varicocele

• Usually asymptomatic. Often incidental finding in routine examinations for male infertility.
• Palpable mass in the spermatic cord, increasing with rising and with Valsalva maneuver.
• Scrotal pain, especially with standing
• Testicular atrophy: Normally the testes size varies not more than 20% or 2 ml in comparison to the other side.
• The primary varicocele is almost invariably on the left side. The right (and left) varicocele may be a symptom of a retroperitoneal tumor.

Diagnosis of a Varicocele

Scrotal Ultrasound with Doppler Examination

• Dilatated veins of the spermatic cord [Fig varicocele in ultrasound]? In adults, a venous diameter of more than 3.5 mm is abnormal.
• Reflux of blood during Valsalva maneuver [Fig varicocele in ultrasound]?
• Testicular size: difference of more than 20% or 2 ml?
• Testicular tumor?
• Renal and retroperitoneal ultrasound: Tumor?

Scrotal ultrasound of a varicocele with color Doppler imaging: The left image shows ectatic veins in the spermatic cord. On the right: venous reflux with Valsalva maneuver.

Semen Analysis

A pathological semen analysis (oligozoospermia, asthenozoospermia) may be caused by a varicocele.

Laboratory tests:

An elevated FSH and low testosterone are typical for a testicular dysfunction due to a varicocele.

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