What is varicocele in men? What is a varicocele? Signs of a varicocele.

Below we will look at the signs of varicocele in men in the photo depending on the stage.

1st stage

An alternative name is hidden varicocele, in which no visible signs changes in the spermatic cords, and the disease itself is often asymptomatic (without pain).

You can feel nagging pain only during severe physical strain - exhausting workouts or prolonged lifting of weights.

The disease cannot be determined even during palpation - Dopplerography and ultrasound are required to determine functional pathological changes.

A man who has a family and children can have the first degree all his life, but not cause any inconvenience to the patient. Considering the irregularity of men seeking preventive examinations, doctors more often diagnose grades with visible manifestations of varicocele in men.

Symptoms of varicocele - photo of stage 1:

2nd stage

It is possible to determine obvious changes in the veins inside the scrotum in a certain position only if the patient is in a standing position.

Positioning the patient on the couch (lying down) does not lead to the appearance of protruding veins, which have already appeared inside the leather pouch the shape of a so-called bunch of grapes. Despite pronounced reflux and severe changes in the veins on the testicles in men (photo below), the shape of the testicle does not change and corresponds to a healthy one.

What does varicocele look like in men - photo of stage 2:

3rd stage

You can detect swollen veins protruding through the scrotum with the naked eye if the patient has the third stage of varicocele. Pathological changes do not disappear when changing body position and are observed in horizontal and supine body positions.

Almost always the testicles are changed in size (reduced), the scrotum droops significantly, and the body of the testicle with its appendages is lowered.

A patient with this stage complains of frequent pain due to testicular varicocele, which occurs even without physical activity.

What is varicocele in men - this is a photo of stage 3:

What threatens the third stage?

If testicular varicose veins in the photo above are your case, be prepared for the following complications:

. Impaired lymph flow leads to fluid retention inside the scrotum. As a result, its size increases significantly (2–4 times): the scrotum inflates and looks like a filled ball.
testicular atrophy. Visual signs are a severe decrease in size, leading to a reduction or complete cessation of sperm production.
epididymitis. Acute inflammation of the testicle due to improper outflow and inflow of blood.
thrombophlebitis of the inguinal veins. The appearance of a blood clot complicates the transport of oxygen and nutrients to the appendage. Diagnosed only by laboratory methods.

The third stage is considered the only option for correction, especially if the varicocele is aggravated by other diseases.

How to determine varicocele yourself?

Having studied each stage step by step, we can definitely say that varicocele can be determined by yourself only from the second stage, if you use the palpation method.

Determination of the first stage is permissible solely on the basis of the appearance of uncomfortable conditions characteristic of varicocele.

Preventive measures that involve studying the condition of the genital organs will also provide invaluable support.

Self-examination of the testicles is carried out by gently palpating the scrotum for the presence of varicocele without any preparatory procedures.

During the study of the spermatic cord, one should be wary of its increase and the appearance of tuberosity, which is felt tactilely.

Possible pain sensations: localization of pain and its nature

How does a testicle hurt with varicocele? Discomfort in men is concentrated in the lower abdomen: nagging pain affects the left or right side (based on the location of the varicose veins).

E if varicocele is paired, then the pain syndrome is concentrated in the middle of the solar plexus and periodically radiates directly to the scrotum, lower back, thigh or penis.

Patients also note burning sensation(typical with the additional development of an infectious lesion) and stabbing pain in the testicles with varicocele along the entire length of the affected spermatic cord.

Fact. A cosmetic defect in varicocele can initiate the appearance of sexual complexes.

Which doctor should I see?

Contact a urologist or andrologist helps to undergo the necessary examination and get the correct one depending on your health condition.

At the first stage, conservative methods of correction are acceptable; for all subsequent stages, surgery is indicated.

If a man is of reproductive age, then the doctor may refer the patient to study the condition of the sperm, which is performed after obtaining a spermatogram.

Detection of varicocele by an experienced urologist is not very difficult- physical changes are visible to the naked eye.

The exception is stage 1 of the expansion of the spermatic cord, which is determined only through research.

If pronounced signs of the disease are detected, a man should definitely consult a specialist in order to prevent the development of complications, which include both the appearance of side diseases and complete loss of fertility.

Useful video

A lot of important information about varicocele in the “Live Healthy” program:

Only in the groin area. The veins of the spermatic cord are affected. If surgery has not been performed, then in the future such patients have a high risk of impaired spermatogenesis and the development of infertility.

Varicose veins of the spermatic cord

This disease is a purely male pathology. The process involves vessels located near the testicles.

This is a non-infectious disease in which the veins of the spermatic cord dilate. Most often, the pathological process is one-sided. In most cases, varicose veins are detected on the left. This is due to the anatomical features of the male genital organs.

Pathology has the following distinctive features:

may be asymptomatic;
does not pose a health hazard;
can only be treated surgically;
often diagnosed in.

This disease does not disappear on its own. Many men live with the pathology for years without even knowing it exists. The prevalence of varicose veins among men reaches 17%. Every fifth teenager aged 14-15 years suffers from this disease. Left-sided varicocele on the testicle develops in more than 90% of cases.

In 2-12% of patients, both venous plexuses are involved in the process. When examining men with varicocele, it was found that 20-70% of patients have spermatogenesis disorders. This is due to the fact that against the background of vasodilation and blood stagnation, the local temperature increases. These changes negatively affect the maturation of male germ cells, which is the main cause.

Why do veins expand?

Every experienced surgeon knows what causes this pathology. The following factors play the most important role in the development of the disease:

Physical overexertion

poor functioning of venous valves;
blood stagnation as a result of a sedentary lifestyle;
physical stress;
weightlifting;
underdevelopment of connective tissue;
disruption of the formation of veins during the process of organ formation;
increased pressure in the renal vein.

Appears for various reasons. Triggering factors include chronic constipation, overload, and prolonged standing. With varicocele, the causes of pathology include increased pressure in the abdominal cavity. Against this background, the veins gradually stretch, dilate and fill with blood. A small nodule forms.

The doctor can feel it during the examination. Of great importance is such a factor as the relative position of the superior mesenteric artery and the renal vein. The degree of vascular dilation varies. Varicose veins are often visible to the naked eye, or changes are revealed only during ultrasound. With varicocele there are no stages.

How does the disease progress?

You need to know not only what causes this pathology, but also what its clinical symptoms are. Most often, signs of the disease are detected in adolescence. This often happens during conscription for military service after graduation. In most cases there are no complaints.

Varicocele on the left may manifest itself with the following symptoms:

enlargement of the scrotum;
its omission;
moderate pain on the affected side;
feeling of heaviness;
decrease in the volume of the left testicle.

Pain is a variable symptom. It has the following features:

aching;
worsens in an upright position of the body, during physical work and after sexual contact;
weakens when a person lies on his back.

Signs of varicocele at grade 0 are not detected during palpation and examination. They are identified in the process of instrumental research. 1st degree is different in that varicose veins are determined in a standing position. Dilated veins are not visible to the eye. With grade 2 varicocele, the nodules can be palpated in horizontal and vertical positions.

During palpation, mild pain may occur. Grade 3 is different in that dilated vessels can be seen with the naked eye. In such men, the pain becomes constant. The direct connection with physical activity disappears. With varicocele, the consequences can be unfavorable for sick men.

What should the examination be like?

All men should know not only what varicocele is, but also how to identify it. This vascular pathology does not cause difficulties in terms of diagnosis.

If a varicocele is suspected, treatment is carried out after a comprehensive examination. It is organized by a phlebologist or vascular surgeon.

First, a detailed history is collected. Risk factors for developing the disease are identified. This pathology can appear for various reasons.

Ultrasound of the scrotum

A physical examination (palpation) is required. The veins are palpated while the person is standing or lying on the couch, as well as at rest and during straining. During palpation, tortuous, dilated and soft vessels of the pampiniform plexus of the spermatic cord are determined.

If necessary, the following instrumental studies are carried out:

Ultrasound of the kidneys and scrotum;
spermogram;
thermometry.

Sometimes the development of varicocele disease is associated with another pathology. In this case, varicose veins occur secondaryly. A common cause is. Not everyone knows how to determine varicocele. This pathology can be detected using computed tomography and magnetic resonance imaging.

Rheography may be needed to assess blood flow in the affected area. What varicocele affects is known to all phlebologists: the main complication is infertility. To assess testicular function and spermatogenesis in case of varicocele disease, a semen analysis is required. During it, a decrease in the total number of germ cells and their activity is often detected.

Therapeutic tactics for varicocele

Many men wonder whether varicoceles can go away on their own.

The changes occurring in the vessels are irreversible. If there are no symptoms with varicocele and stage 0 or 1 of the disease is detected, then surgery is not required.

The peculiarity of this pathology is that it does not progress. One degree does not transfer to another.

Treatment methods for varicocele are few. Only surgical intervention can help the patient. Indications for surgery are:

severe pain syndrome;
changes in ejaculate parameters (asthenozoospermia and oligospermia);
testicular underdevelopment (for teenagers).

In some cases, patients agree to radical treatment if there is a pronounced cosmetic defect in the scrotum area. For varicocele, the classification is known to every surgeon. With stage 3 disease, severe sagging of the scrotum is possible. This can cause difficulty in movement. In such a situation, surgical treatment of varicocele is justified.

The most frequently performed types of operations are:

vein embolization;
raising the testis;
vessel ligation;
excision of an enlarged vein.

In how to treat varicocele, endoscopic operations have recently been widely used. Such manipulations are less traumatic. Treatment methods for testicular varicocele include mini-access surgery. In some cases, X-ray endovascular occlusion is used.

Vein excision is performed less and less often. Before treating varicocele, you need to ask the patient if he has children and whether he plans to have them in the future. This question is very important, since this pathology can cause infertility. Not everyone knows what will happen if varicocele is not treated. The primary form of the disease does not pose a threat. With primary dilation of the vein, it is necessary to cure the underlying disease (thrombosis). With varicocele, complications include disruption of spermatogenesis (the process of formation of male germ cells).

Forecast and preventive measures

It is necessary to know not only why varicocele develops, why this disease is dangerous, but also how to prevent it. The main influencing factor is stagnation of venous blood. In order to reduce the risk of developing this pathology, you must follow the following rules:

do not lift heavy objects;
treat chronic intestinal diseases;
normalize stool;
move more;
do not stand in one position for a long time;
give up alcohol.

When a varicocele develops, restoration of the vessel wall does not occur. The health prognosis is favorable. Identification of this pathology in young people gives a deferment from military service. Recovery after varicocele and surgery occurs quickly (within a few days). Thus, varicose veins are a very common pathology among the male half of the population.

Video

Varicocele is a change in the veins in the area of the spermatic cord, which is formed as a result of the effects of varicose veins and occurs in combination with a violation of the outflow of venous blood from the testicle. Varicocele, the symptoms of which manifest themselves in the form of bursting and nagging pain, heaviness and discomfort localized in the scrotum, as well as visible venous expansion, often occurs due to inflammation and rupture to which varicose vessels are exposed, which is accompanied by hemorrhage in the scrotal area.

Against the background of a progressive form of the disease, the affected testicle decreases in size, spermatogenesis is affected, and early male menopause and infertility begin to develop.

general description

Regarding the disease in question, the World Health Organization has its own data, from which it follows that the incidence of varicocele among men is observed in about 17% of cases. Significant fluctuations in the incidence rate can be observed depending on the territorial location, as well as on the age of men. For example, in about 19.3% of cases, varicocele is present in adolescents, while military age indicates the presence of this disease in young men in 5-7%.

Quite often, the course of the disease is characterized by the absence of symptoms, which is why, accordingly, men are in no hurry to provide them with appropriate medical care. An ultrasound scan determines the presence of signs of the disease in question in 35% of cases in those men who have reached puberty. Moreover, the vast majority of cases indicate a left-sided form of varicocele, caused by the anatomical differences that exist in the venous systems on the right and left sides. The development of a right-sided form of varicocele is relevant in 3-8% of cases, bilateral - in the range from 2 to 12%.

Classification of varicocele

In accordance with the above characteristics of the disease, its corresponding classification is distinguished:

depending on the side of the lesion:

left-sided varicocele;
right-sided varicocele;
varicocele bilateral.

depending on the characteristics of the etiology:

primary varicocele;
varicocele symptomatic;
functional varicocele (often defined as secondary varicocele).

depending on the characteristics of venous reflux:

in combination with renotesticular reflux;
in combination with ielotesticular reflux;
in combination with a mixed form of reflux.

depending on the degree (I, II, III);
depending on the combination of disease in the renal vein with hypertension:

in combination with renal vein hypertension syndrome;
without renal vein hypertension syndrome.

depending on the definability of the disease through the use of physical methods:

subclinical;
clinical.

In accordance with the stages of dilation of veins in the pampiniform plexus in combination with changes inherent in testicular trophism, the following stages of the disease are distinguished:

Stage I – manifestations of varicose veins are noted only by palpation, which is produced when the patient strains to assume a vertical body position;
Stage II – dilated veins are determined visually, there are no changes in the consistency and size of the testicles;
Stage III – dilatation in the pampiniform plexus of muscles is pronounced, the testicle decreases in size, and its consistency is also subject to changes.

In rare cases, there is a possibility of transition from one stage to another.

Causes of varicocele

The development of the disease we are considering occurs as a result of the fact that the valves located in the veins, which normally prevent the flow of blood in the opposite direction, “fail” or function, but not well enough for proper results. As a result, there is an increase in pressure in the veins (for example, when the body assumes a vertical position or as a result of physical stress), the pressure is transmitted in the opposite direction, thereby provoking a gradual expansion in the volume of the venous vessel. Accordingly, the course of the pathological process in this form also leads to dilation of the veins surrounding the spermatic cord.

Another cause of varicocele is also distinguished by the peculiarities of the anatomical relationships formed between the superior mesenteric artery and the renal vein, in which the aorto-mesenteric “tweezers” are formed.

Over time, exposure to increased pressure leads to an increase in veins in size, to their expansion and stretching. Based on the strength of the vein walls of each individual individual, as well as the magnitude of the impact of venous pressure, stretching can reach different degrees.

The venous network surrounding the testicle becomes larger and larger in size, while pronounced manifestations of the disease in some cases lead to the fact that the testicle becomes as if immersed in a sponge consisting of venous vessels. Such a peculiar “cushion” of vessels surrounding the testicle leads to the loss of the thermoregulatory function of the scrotum, as a result of which the testicle does not cool. Thus, the low temperature required for sperm production is absent, resulting in suppression of normal spermatogenesis. Taking into account all the listed features of the course of the disease, it can be noted that varicocele, according to experts, is one of the main factors that provoke infertility in men.

Among the factors that provoke it are thus:

An increase in temperature in the testicle to body temperature (under normal conditions, the testicles are characterized by a lower temperature than body temperature, which thereby determines normal indicators for the course of spermatogenesis);
Testicular hypoxia (that is, its oxygen starvation, ischemia);
Reverse discharge of biologically active components from the kidneys and adrenal glands;
The accumulation of free radicals in the tissues of the testicle, which act as the strongest cellular poisons and, accordingly, damage it.

In addition to the listed influencing factors, varicocele can also appear as a result of congenital weakness, which characterizes the vascular wall as a whole, while the congenital form of the disease manifests itself mainly for this reason. It is noteworthy that almost always one of the patient’s relatives is faced with varicose veins of the extremities, heart valve defects, and other types of manifestations indicating insufficiency inherent in connective tissue. Often these diseases are concomitant with each other.

Varicocele: symptoms

As for the symptoms characteristic of varicocele, they are determined based on the degree of expansion to which the veins have undergone. Stage I is characterized by the absence of any symptoms; varicose veins are determined randomly during a medical examination.

As for the features of stage II, it is characterized by the presence of complaints from patients about pain localized in the scrotum area, while the severity of their manifestations can vary significantly. In some cases, there is discomfort while walking, and sometimes sharp pain may occur, and their nature makes them more similar to neuralgic pain.

Increased sweating may occur, and a burning sensation may occur in the scrotum area. Often patients diagnosed with varicocele experience sexual dysfunction. Physical examination reveals dilated veins that reach the lower pole, descending from the testicle below. In the affected area, the testicle descends, which leads to asymmetry of the affected half of the scrotum and its sagging.

Stage III of the disease is characterized by a loss of connection between physical activity and pain. In this case, pain becomes a constant phenomenon for the patient, and this manifestation does not disappear during sleep. External examination determines the presence of multiple clusters of veins. In addition, an increase in the size of the scrotum and the severity of the asymmetry characteristic of it in the disease are becoming a current phenomenon.

Diagnosis of varicocele

Diagnosis of varicocele quite often occurs only on the basis of examination in combination with palpation of the pampiniform plexus (which has the appearance corresponding to its name) when the patient assumes a standing position. Palpation at a more distinct level is carried out using the Valsalva maneuver (that is, a test with straining, which involves increasing pressure through the abdominal cavity, resulting in increased blood flow to the veins of the testicle).

If the veins are significantly enlarged and there is no doubt about the diagnosis, there is no need for additional examinations.

If the severity of the disease in question is insignificant, it is necessary, in this case, to carry out Doppler sonography. These examination methods must be carried out both in a lying and standing position, otherwise there is simply no point.

In addition to the above, the diagnosis of varicocele also requires a spermogram, and it is done at least twice, with an interval between procedures of 4-12 weeks. Sexual abstinence for a spermogram is necessary for a period of 2-7 days.

Varicocele: treatment

Similarly, in which the localization of the pathology is concentrated in the leg area, with varicocele the only effective way is surgery, performed in any of the existing forms.

Considering the fact that the disease itself is not dangerous, and, as a rule, the symptoms during its course do not bother the patient, an expedient solution is to eliminate the need for surgical intervention when a varicocele is detected in an adult man.

The operation becomes mandatory in the following cases:

in the presence of severe pain in the testicular area;
with infertility on the male side, which arose against the background of decreased motility, quality and quantity of sperm;
with an aesthetic defect formed against the background of a disease in the scrotum area;
There is a stop in the growth of the testicle affected by the disease, which is particularly important during the patient’s puberty.

In general, it can be noted that the issue regarding the close connection between varicocele and infertility today is quite controversial, as, in fact, the need for surgical intervention is also disputed.

A number of experts in this regard are of the opinion that, as a preventive measure for subsequent infertility, surgical intervention in the case of morbidity in children/adolescents is necessary, regardless of the situation and stage of development of the disease, because the accumulation of blood in the testicles leads to irreversible damage to the spermatogenic epithelium, which in accordance with this feature, it is not restored under any conditions or treatment, thereby causing certain problems in the reproductive sphere.

Meanwhile, there are statements that varicocele is not the cause of infertility; moreover, surgical intervention for this disease is required only when severe pain occurs and when the testicle is underdeveloped on the affected side, that is, with specific indications for surgery

Taking a more detailed look at the disease in the context of possible infertility, an interesting point can be highlighted. In particular, the issue of changes in spermatogenesis, which was in a suppressed state before surgery, is considered.

A study was once conducted on this matter, which lasted about 2 years, examining 986 cases of the disease, accompanied by problems with fertility. The results after surgery in a specified number of patients diagnosed with varicocele were analyzed. As it turned out, after it, about 70% had improved quality characteristics of sperm, while in 53% of cases, the wives of the test men became pregnant. It is also known that men with varicocele who refuse surgical intervention become fathers only in 10-15% of cases.

As for the surgical methods of therapy used today, these include open surgery and mini-access surgery, endoscopic surgery, as well as microsurgical testicular revascularization.

When examined by a specialist, the main thing is to determine the reasons that provoked varicocele, because in some cases the appearance of the disease is caused by a kidney tumor. If there are symptoms characteristic of varicocele, consultation with a urologist and phlebologist is necessary.

Varicocele-varicose veins of the spermatic cord are common diseases of the children's reproductive system. In children and adolescents, varicocele occurs in 12.4%-25.8% (Isakov Yu.F., 1969; Erokhin A.P., 1979). Serious disorders of spermatogenesis are observed in approximately 30% of patients operated on in childhood (Kondakov V.T., Pykov M.I., 2000). In total, more than 40% of childless marriages are associated with varicose veins of the testicular veins (Tiktinsky O.L., 1983; Godlevsky D.N.), which negatively affects the modern demographic situation and is obvious evidence of poor treatment.

Causes of varicocele.

Histological and immunohistochemical studies have proven that the development of varicocele is based on disturbances in the embryogenesis of the venous network of the testicle and spermatic cord, expressed in a scattered type of vein structure, when instead of one vessel a network of muscle-type veins of different morphological characteristics is found; violations of collagen formation in the walls of blood vessels (absence of type 4 collagen in the walls of venous vessels, significant disturbances in the formation of type 3 collagen). All these changes lead to discomfort in the blood outflow system, to the development of compensatory processes, their destabilization and the formation of varicocele. Changes in the wall of veins (dilation, sclerosis, destruction of valves), revealed in biopsy specimens, superimposed on the congenital pathology of vessel formation, are secondary in nature. They may be a consequence of the absence of a valve at the mouth of the testicular vein, increased pressure in the left renal vein, venous reflux, retrograde blood flow due to fewer valves in the left testicular vein compared to the right, and damage to the valves.
In the prepubertal and early puberty periods, boys grow rapidly, which is reflected in an additional increase in pressure in the pampiniform plexus due to an increase in orthostatic pressure. During the same period, there is an increased flow of arterial blood to the testicle. The increasing outflow of blood in connection with this evenly stretches the testicular vein, pushing the valves apart and thus opening the way for the retrograde flow of blood from the crowded renal vein into the testicular vein. Under the influence of significantly increased pressure, varicose deformation of the walls of the altered network of testicular veins and the pampiniform plexus develops.
Prolonged stagnation of venous blood leads to an increase in temperature, the development of sclerotic changes in the testicle and impaired differentiation of the spermatogenic epithelium. These disorders can also be caused by blood shunting, when arterial blood, bypassing the microvasculature of the testicular parenchyma, enters directly into the venules, and circulatory hypoxia of the testicular tissue develops, which is one of the main factors in the formation of pathospermia and infertility. This damages the blood-testis barrier, the function of which is performed by the basement membrane and Sertoli cells. An autoimmune process develops. Circulating antibodies that appear in the general bloodstream for various reasons can overcome the blood-testis barrier of the right testicle and cause disruption of its morphology and functions. In the future, this may manifest itself as a decrease in overall spermatogenesis, the appearance of pathological forms of sperm and the development of infertility.

Classification. Forms and types of varicocele.

There are several classifications of varicocele.
1. on the affected side:
a.) left-sided;
b.) right-sided;
c.) two-sided;
2. by etiology:
a.) primary;
b.) symptomatic;
c.) functional (a number of authors classify it as secondary);
3. according to the nature of venous reflux:
a.) with renotesticular reflux;
b.) with ileotesticular reflux;
c.) with a mixed version of reflux;
4. by degree:
a.) first;
b.) second;
c.) third;
5. in combination with hypertension in the renal vein:
a.) varicocele with hypertensive syndrome in the renal vein;
b.) varicocele without hypertensive syndrome in the renal vein;
6. by determination by physical methods:
a.) clinical;
b.) subclinical.
Primary varicocele (in the domestic literature “idiopathic”) is caused by the incompetence or pathology of the valves of the testicular vein, developing against the background of its congenital changes (lack of type 4 collagen in the vein wall and absence of type 3 collagen).
Secondary varicocele is caused by venous hypertension in the renal vein and reverse blood flow from the renal vein through the testicular vein into the pampiniform plexus and then through the external spermatic vein system into the common iliac with the formation of a compensatory renocaval anastomosis. Venous hypertension in the kidney itself can be caused by organic stenosis of the renal vein due to a scar process in the tissue surrounding the vein, kidney tumors, annular renal vein, kidney lesions such as “arteriovenous fistulas” of a post-traumatic or tumor nature, nephroptosis, thrombosis of the renal vein, which in pediatric surgical practice is extremely rare.
An intermediate position is occupied by functional stenosis of the renal vein (functional varicocele), i.e. compression in orthostasis of the left renal vein between the superior mesenteric artery and the aorta with an excessively acute angle of its origin. The angle between the aorta and the superior mesenteric artery varies depending on the position of the body. In clinostasis, the angle is greater and the outflow of the renal vein is not impaired. In orthostasis, the venous flow is distorted and directed from the renal vein down the testicular vein into the pampiniform plexus; in clinostasis, its direction is normal - from the testicular vein to the renal vein. Sharp congestion of the pampiniform plexus in a standing position disappears when the patient moves to a lying position. In the Russian literature, this condition is known as “aortomesenteric tweezers” and occurs with a frequency of about 18% among all children with varicocele. In our observation of 120 children with varicocele, not a single child had this condition confirmed either by Doppler sonography or angiographic examination.
It must be said that the previously used classification of varicocele by stage has now somewhat lost its clinical significance, since numerous studies have not revealed a correlation between the stage of varicocele and the degree of disturbance of spematogenesis.
The identification of clinical and subclinical forms of varicocele is of great importance. Symptoms of varicocele in subclinical forms are not detected by physical examination and are detected by ultrasound examination methods. As a rule, patients with subclinical forms are identified during examination for infertility already in adulthood. That is why it is so important to identify this disease early and, if possible, begin conservative therapy aimed at improving intraorgan blood flow in the testicle.
Varicocele develops predominantly on the left side (70-90% of cases). Its localization on both sides is determined by various authors with a frequency of 14-23%, on the right side - up to 10.6%, which, as a rule, indicates the presence of vascular anomalies in the patient, or space-occupying formations of the retroperitoneal space.

Complaints with varicocele. Clinical picture.

Symptoms of varicocele are usually scant. The following options are available:
1. patients do not present significant complaints and the diagnosis is made during screening examinations, and in adulthood - during examination for an infertile marriage;
2. patients complain of periodic nagging pain in the corresponding half of the scrotum. Pain may intensify with physical activity, sexual arousal and in an upright position of the body (due to increased venous pressure);
3. patients complain about the presence of dilated veins in the scrotum (“bundle of worms” detected during self-examination and drawing the patient’s attention, especially during puberty.
The clinical manifestation of secondary varicocele associated with venous hypertension may be pain in the lumbar region of a dull or stabbing nature (sometimes there is severe pain, fever, oliguria) and blood in the urine (recurrent macro- and microhematuria, proteinuria).

Diagnostics. Examination.

Examination of children with varicocele is recommended to be carried out according to a single algorithm, which allows for the most rational approach to the choice of diagnostic methods and treatment.
The examination begins with a detailed history taking, and attention is paid to the duration of the symptom and the presence of trauma to the lumbar region. Next, the patient is examined standing and lying in a warm room. With the patient in an upright position, it is necessary to examine both spermatic cords in order to identify the difference in their sizes. Light traction on the testicle is necessary to reduce the effect of the cremasteric reflex. Any signs of testicular atrophy should be noted. Functional tests are performed - Ivanissevich and Valsalva (“cough push”). The “cough impulse” test is performed by palpating the spermatic cord. When coughing in the area of the external inguinal ring in sick children, an impulse is detected that occurs as a result of the transmission of increased intra-abdominal pressure to the veins of the pampiniform plexus; in healthy children this impulse is usually not detected. Ivanissevich’s technique is also demonstrative: in a child in a supine position, the spermatic cord at the level of the outer ring of the inguinal canal is pressed to the pubic bone. In this case, the veins of the cord in the scrotum are not filled. If you do not stop the compression of the cord, filling of the veins does not occur even when the child is transferred to a vertical position. If you stop pressing on the cord, the pampiniform plexus will immediately fill up.
Data from a physical examination make it possible to identify the presence and degree of dilation of the veins of the spermatic cord, to suggest the nature of hypertension in the renal vein - persistent or transient, to determine the presence and degree of testicular atrophy on the side of the varicocele.
Laboratory tests include a general urine test to detect proteinuria and microhematuria, and in adult patients - microscopic analysis of ejaculate (in childhood, due to the developing organism, this method is not only unreliable, but also ethically unlawful).
The following methods for diagnosing varicocele are proposed in the literature: contact scrotal thermometry, thermography, radioisotope scanning of the scrotum. These methods are currently optional. Their use is advisable only in some cases when subclinical varicocele is suspected.
Currently, the indications for the use of angiographic examination are expanding:
1. bilateral varicocele
2. recurrent varicocele
3. rapidly progressing varicocele
4. combination of varicocele with hematuria, arterial hypertension, pain in the lumbar region
5. the first stage in transvascular embolization of the testicular vein.

Rice. discharge into the femoral vein.

Rice. occlusion.

Rice. control

The “gold standard” in the diagnosis of varicocele is currently considered to be scrotal Doppler echo, which is performed using ultrasound machines with a Doppler sensor. The study is performed in ortho- and clinostasis and using a modified Valsalva maneuver (straining the abdominals while lying down). It can also help identify subclinical varicoceles that are difficult to palpate. During an ultrasound examination of the scrotum, three sizes of both testicles, the total volume of the gonads are measured, and they are compared with the age norm and with each other (if the difference in volume is more than 20%, we can talk about testicular hypoplasia and hypotrophy). The diameter of the veins of the pampiniform plexus on both sides is examined at rest and at the height of the modified Valsalva maneuver, the presence, duration and speed of reverse blood flow are recorded, the resistance index of the testicular vessels is measured (with varicocele, a drop in the resistance index below 0.6 is usually observed, which indicates severe hypoxia of the testicular tissue; in the case of a subclinical course of the disease, normal or increased values of the resistance index are possible, tending to decrease with the progression of the vricocele).

Also, Doppler ultrasound will, in some cases, allow one to identify all three main components of venous reflux - renotesticular, ileotesticular and their combination (mixed).

Modern methods of treating varicocele. Types and methods of operations.

Currently, treatment of varicocele is carried out in accordance with the variant of intraorgan circulation disturbance identified using Doppler sonography. The goal of treatment is to eliminate venous reflux through surgery. Treatment of varicocele is surgery.
There are several options for surgical interventions:
1. occlusive operations at various levels of the testicular vein;
2. microsurgical operations - application of various types of veno-venous anastomoses.
There are the following types of operational access:
· retroperitoneal (operations of Palomo, Ivanissevich, Bernardi);
· inguinal and subinguinal (operations Marmara, Yakovenko);
laparoscopic;
· interventional vascular (selective transvenous embolization).
Currently, for the treatment of varicocele, Palomo and Ivanissevich operations are used, performed both using laparoscopic techniques and open retroperitoneal access, as well as transvenous embolization. A combination of both methods is possible.

Video fragment of laparoscopy for varicocele.

http://www.youtube.com/watch?v=a_3iVILQpKA

Drawing. Varicoceles, surgery.

The prognosis for the treatment of varicocele is favorable.

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This is a varicose change in the veins of the spermatic cord, accompanied by a violation of the venous outflow from the testicle. It manifests itself as pulling and bursting pain, a feeling of discomfort and heaviness in the scrotum, and visible dilation of the veins. Inflammation or rupture of varicose veins may occur with bleeding into the scrotum. Progressive varicocele leads to a decrease in the size of the affected testicle, impaired spermatogenesis, the development of early male menopause and infertility. Diagnostics - ultrasound of the scrotum with Doppler sonography. Treatment can be minimally invasive (vascular embolization) or surgical, carried out using various techniques.

General information

Varicocele is a disease caused by varicose veins of the spermatic cord. In itself, varicocele does not threaten the patient’s life and, as a rule, does not cause him much concern. The main danger of varicocele is that the disease can lead to the development of male infertility. When analyzing ejaculate, spermatogenesis disorders are determined in 20-70% of patients with varicocele. There is confirmed evidence of a correlation between the degree of sperm production impairment and the duration of the disease. In some cases, varicocele is accompanied by pain of varying intensity.

According to WHO, varicocele affects 15-17% of men. The incidence rate can vary significantly depending on age and place of residence. At the age of 14-15 years, varicocele is detected in 19.3% of adolescents, and during conscription for military service - in 5-7% of young men. Often, varicocele is practically asymptomatic and men do not seek medical help. When performing an ultrasound, signs of varicocele are detected in 35% of men who have reached puberty. In the overwhelming majority of patients, left-sided varicocele is detected, which is due to anatomical differences in the venous systems of the testicle on the left and right. On the right, varicose veins of the spermatic cord develop in 3-8% of patients, on both sides - in 2-12%.

Causes of varicocele

The reason may be insufficiently good functioning of the valves of the veins of the spermatic cord. Venous valves, which normally prevent the reverse flow of blood, cannot cope with the increased pressure under increased stress (physical stress, vertical body position). Due to increased pressure, the veins gradually expand, eventually forming tumor-like venous nodes.

Modern studies conducted in the field of phlebology have identified several causes of primary (idiopathic) varicocele: insufficiency of the connective tissue forming the venous wall, underdevelopment or changes in the valve apparatus of regional (veins of the testicle and spermatic cord) and main veins, or disruption of the formation of the inferior vena cava in intrauterine period.

Certain anatomical features can cause increased pressure in the renal vein system. Venous hypertension causes incompetence of the testicular vein valves. A bypass path gradually develops; in patients, a reverse flow of blood is detected from the renal vein into the testicular vein, and from there into the pampiniform plexus. An increase in intra-abdominal pressure during prolonged tension of the anterior abdominal wall (constipation, intense physical activity, constant stay in an upright position) may act as a provoking factor leading to the development of varicocele.

Secondary (symptomatic) varicocele is a complication of a space-occupying process in the kidneys, pelvis or retroperitoneum. In this case, the cause of the development of the disease is an obstruction to the normal outflow of blood from the veins of the spermatic cord.

Classification

The following degrees of varicocele are distinguished:

0 degree. Signs of varicocele are not detected by palpation. Varicose veins are detected only during instrumental studies (Dopplerography, ultrasound).
1st degree. In a lying position, the veins cannot be palpated; in a standing position, the dilation of the veins is determined by palpation.
2nd degree. When palpated in a lying position and in a standing position, dilated veins are determined.
3rd degree. The dilation of the veins of the spermatic cord and testicle is visible to the naked eye.

Symptoms of varicocele

The severity of clinical manifestations of varicocele depends on the degree of dilation of the veins. At stages 0 and 1 of the disease, there are no symptoms of varicocele. Varicose veins are usually detected during a routine examination.

With stage 2 varicocele, patients complain of pain in the scrotum. The severity of pain can vary significantly. A number of patients note only discomfort when walking; some patients experience sharp pains, reminiscent of neuralgia in nature. Increased sweating and a burning sensation in the scrotum area are possible. Many patients with varicocele complain of sexual dysfunction. During the physical examination, dilation of the veins reaching the lower pole of the testicle and descending below it is determined. The testicle on the affected side descends, causing asymmetry and drooping of half of the scrotum.

With stage 3 varicocele, the connection between pain and physical activity disappears. The pain becomes constant and bothers patients at rest and at night. An external examination reveals numerous clusters of veins. The scrotum enlarges, its asymmetry becomes more pronounced.

Diagnostics

In the vast majority of cases, making a diagnosis of varicocele does not present any difficulties for a phlebologist surgeon. The patient is interviewed to determine the circumstances of development and duration of the disease. Pay attention to possible injuries to the lumbar region.

In some cases, an external examination reveals dilated grape-shaped nodes. The tortuous, vermiform soft veins of the pampiniform plexus are identified by palpation. In some patients, the testicle on the affected side decreases in size and becomes flabby.

For varicocele, palpation examination must be carried out in a horizontal, vertical position and with straining (when performing the Valsalva maneuver). If dilated veins on the right are not detected when standing and straining, most likely we are talking about a primary varicocele. Dilation of the veins with bilateral or right-sided varicocele, remaining in a horizontal position, may indicate a symptomatic process.

To exclude space-occupying formations that cause symptomatic varicocele, ultrasound of the kidneys and retroperitoneum is mandatory. Vascular thrombosis, as well as diseases leading to the development of secondary varicocele, can be detected by MRI or CT. Patients who have reached adulthood are prescribed a spermogram (ejaculate analysis). Often with varicocele, asthenozoospermia (reduced activity) and oligospermia (decreased number) of sperm are detected.

Thermometry, ultrasound of the scrotum, Dopplerography, thermography and rheography are optional diagnostic methods. However, the use of ultrasound and Doppleroscopy is often used to identify subclinical forms of varicocele. To determine treatment tactics, contrast studies are performed: retrograde renal-testicular venography, transscrotal testicular phlebography. In some cases, antegrade venography is performed before, during and after surgery.

Treatment of varicocele

With secondary varicocele, it is necessary to treat the underlying disease. For primary varicocele of degrees 0 and 1, surgical treatment is not required. Measures are being taken to eliminate stagnation in the pelvis (limiting physical activity, preventing chronic constipation, etc.). Sometimes elderly patients experience a positive effect when wearing a suspensor. For grade 2 varicocele, accompanied by intense pain, and grade 3 disease, surgical treatment is necessary. Indications for surgical treatment for varicocele: asthenozoospermia and oligospermia; delayed testicular growth on the affected side during puberty; cosmetic defect.

There are three groups of surgical interventions for varicocele: testicular elevation, varicocele embolization and vein excision. Excision of veins can be performed from subinguinal (at the entrance to the inguinal canal), inguinal (at the inguinal canal) or retroperitoneal (at the exit from the inguinal canal) approach. In recent years, microsurgical and laparoscopic ligation of dilated veins has been increasingly performed for varicocele, which can significantly reduce the rate of complications and relapses. In some cases, in children and adults, good results are achieved with X-ray endovascular occlusion of the testicular vein.

Prevention

In some cases, a good effect in the initial stages of varicocele can be achieved by eliminating congestion in the pelvic organs. Patients are advised to limit prolonged physical activity, normalize bowel movements, eliminate alcohol, take vitamins, have a regular sex life, and normalize their work and rest schedule.