Varicocele is the presence of varicose veins of the testis and spermatic cord.
- 1 Epidemiology
- 2 Reasons for varicocele
- 3 Predisposing factors
- 4 Pathogenesis
- 5 Degrees of development of the disease
- 6 Symptoms of varicocele
- 7 Treatment of the disease
This pathology is one of the most common among the male population and very often leads to negative consequences. It is found, basically, at the age of 15 to 25 years, on average in 15% of men. The combination of this disease with infertility occurs in 35% of cases with primary and 80% with secondary. Most varicocele occurs in young men during sexual development, rapidly develops to a certain extent and does not increase anymore, very rarely there is a transition of one degree to another .
In 90% of cases, this pathology is left-sided, on the right the disease is very rare. This is due to the fact that the length of the left spermatic vein is larger, and it falls into the vein of the kidney to the left at an angle of 90 degrees, which makes the blood flow on the left side difficult. The right vein is shorter and its confluence occurs in the inferior vena cava with the formation of an acute angle. In some cases, in the presence of malformations( 9% of cases) in the case of a right ovarian vein transition to the right renal vein, varicocele and the right may occur.
Causes of varicocele
This pathology is referred to diseases, the cause of which is not completely established. It is considered to be a varicocele as a polyietic disease, the basic value in the formation of which is the anatomical and physiological prerequisites of .
There are two possible causes:
- Reverse flow of blood through the seminal vein into the groinlike plexus of the spermatic cord from the renal vein( due to the right angle of confluence);
- 2. Periodic infringement of blood outflow from testicles as a result of infringement of the left vein of a kidney between an aorta and an intestinal artery. Characteristic of this is a decrease in the pressure in the prone position and the disappearance of the reverse current.
Distinguish a separate form of pathology - a symptomatic( secondary) varicocele, which can occur on both the left and on the right and develop due to the fact that the seminal vein is compressed by a retroperitoneal tumor or inflammatory infiltrate. It is most often formed as a result of the following conditions: kidney tumors, metastases to retroperitoneal lymph nodes, anatomical narrowing of the veins of the kidneys, a significant increase in pressure in the portal vein, existing renal shunts between the artery and the vein. The main difference of this type of varicose will be its resistance, i.e.in the horizontal position, the filling of the veins does not change. Therefore, if a pathology is found in adulthood or on the right side, the tumor must first be excluded.
There are some factors that contribute to the development of the disease:
- Defects in the valve apparatus of the seed vein( valve failure or lack thereof), resulting in retrograde flow of blood down this vessel and widening of the veins in the plexus of the testicle ;
- Weak walls of veins, resulting in no resistance to blood pressure. Most often this occurs as a result of hereditary predisposition. Virtually always in patients with varicocele there are relatives with varicose veins, flat feet, heart defects, phimosis and other diseases characteristic for the pathology of connective tissue;
- The cord veins have different lengths and small diameters;
- The left spermatic vein flows into the vein of the kidney at an angle of 90 degrees;
- Excessive blood pressure in the vessels of the small pelvis and scrotum. The cause, as a rule, is anatomical changes( vein bend of the testicle, clamping it with vessels, tissue folds), leading to a decrease in the diameter of the vein and increase of pressure in it;
- Other factors: chronic constipation, diarrhea, lifting of gravity, overload of the muscular layer of the abdominal press.
Varicocele in men is considered a clinical manifestation of increased venous pressure in the kidney, which occurs as a result of a violation of blood flow through her vein. Venous hypertension occurs as a result of a blockage of the renal vein thrombus, its location behind the aorta, the pinching of the vein to the left between the aorta and the upper artery of the mesentery( which happens most often) or as a result of a kidney tumor. In the vertical position of the patient, compression of the renal vein occurs, which disrupts the outflow from the kidney and causes an increase in the venous pressure in it.
With the development of narrowing of the veins of an organic nature that occurs as a result of a scar process in the kidney's cellular tissue, trauma, kidney failure, the observed renal hypertension will persist regardless of the position of the body in space. Often this is also accompanied by the presence of protein and red blood cells in the urine. As a result of increased pressure in the renal vein, the function of the valves of the testicular vein will gradually develop. Because of this, additional ways of blood outflow through the collateral veins in the kidney cellulose, intercostal and cavernous veins will be formed.
Also important in the pathogenesis of the disease is the disproportionality of adolescent growth during puberty, which leads to functional failure of the vein valves of the testicle. In addition, adolescents have hypermobility of the kidneys and a pronounced downward shift in the vertical position, which causes tension and changes in the position of the renal and seminiferous veins, and the violation of blood flow in them.
Thus, it is generally believed that the formation of the vein of the testis and varicocele is a reaction of the body to the existing high pressure in the kidney.
Degrees of development of the disease
Classification takes into account the degree of vein plexus expansion and the change in testicular nutrition .The following degrees are distinguished:
- For 1 degree it is characteristic that in the position of a person standing the veins of the plexus are dilated, but below the upper edge of the testicle do not fall. There are no clinical signs;
- With varicocele of 2nd degree , the spermatic vein expands, the cord is stretched and the expanded vein is lowered, while it remains within the projection of the testicle, not protruding beyond its lower edge. There is also an increase in the size of the half of the scrotum and testicle, its descent, a decrease in the tone of the muscle that lifts the testicle. Patients complain of a feeling of heaviness in the scrotum, especially when exercising. On examination and palpation, a nodular enlargement of the veins of the lobate plexus is detected. In the supine position, the veins fall off;
- For the 3rd degree of pathology, the veins are expanded in the standing position, in the form of a conglomerate, which descend to the bottom of the scrotum below the lower end of the testicle. On the affected half there is a thickening of the scrotum wall, its lengthening, a cyanotic skin tone;interlacing of veins;atrophy of the testicle, its significant omission;the absence of a reflex in the muscle that lifts the egg. Patients complain of a feeling of heaviness and pain in the scrotum at rest and under physical exertion, a decrease in tone and performance. In severe cases, inflammation of the veins of the cord is possible.
In the future, regardless of the degree of the disease, there are changes in the second testicle, which leads to the development of infertility. Then, the prostate gland becomes involved and its structure and function are disturbed.
Symptoms of varicocele
The clinical manifestation of this pathology will be either the appearance of pain( 25%), or the development of infertility( also 25%). In the remaining 50% of patients, the disease is asymptomatic.
Patients complain of dull or pressing pains from the affected side, a feeling of heaviness in the scrotum, which appears after physical exertion, sex and long standing in standing position. Also note the omission of the affected half of the scrotum down. When going to the prone position at stages 1 and 2, the scrotum rises and the pain disappears quickly.
The most unpleasant consequence of varicocele may be the development of infertility, as there is a violation of the function of the spermatogenic epithelium and suppression of spermatogenesis. The main causes are:
- Venous blood congestion, which causes an increase in temperature inside the scrotum by 0.5-1.5 ° C, which leads to suppression of the process of sperm formation, since it requires a temperature of 3 ° C below normal for humans;
- Lack of oxygen in the testicles;
- Dysfunction due to narrowing of the lumen of the arteries;
- Stagnation of lymph on the affected side;
- Mechanical compression of the testicle by varicose dilated vessels;
- Thinning of the skin of the scrotum and a violation of its thermoregulatory function;
- A change in the vein wall, resulting in a disruption of its function as a hematotestickular barrier. Tissue tissues become available for the immune system( which under normal conditions does not occur), which perceives them as alien and triggers the autoimmune inflammation process, both in the diseased testicle and in the healthy one.
An asymptomatic variant of the course of the disease is possible, without clinical manifestations and development of infertility, which is accidentally detected during preventive examination.
disease Conservative methods of therapy in this case are ineffective, treatment is performed only in an operative way. Surgery for this pathology is mandatory in the presence of pain in the scrotum or development of infertility, since it is possible to eliminate the symptoms only when the cause is eliminated. In the absence of clinical symptoms, the need for surgery is decided, given the probability of infertility. If a man in the future plans to have children, the operation is done, if not already, then surgery is not mandatory. As a rule, when a disease is detected in a child or adolescent, the veins are removed, if the men are of age, they are most often left.
There are more than a hundred methods of surgical treatment for varicocele. The most common are those in the process of which the anastomosis between the veins of the kidney and the inferior cavity is interrupted, which stops the reverse transfer of blood into the seminiferous vein. The main types of operations:
- type 1 - complete dressing, cutting and removal of varicose veins( endoscopic surgery);
- 2 type - complete removal of the veins of the testicles and their subsequent restoration with the help of plastics.