VARICOCELE PART 1

Dr. Kemi Ailoje 

Veins in the body transport blood from various organs back to the heart. They usually have valves that prevent backwards pool of blood, in other words, they are one-way valves. A varicocele is an expansion of the veins inside the loose pouch of skin holding the testicles (scrotum). It also contains the arteries and veins that deliver blood to the reproductive glands. These veins carry testicular blood, which is devoid of oxygen. Blood pooling in the veins instead of effectively leaving the scrotum or a vein abnormality in the scrotum may lead to a varicocele. These veins are called the pampiniform plexus and it is very similar to varicose veins that can occur in the leg. The pampiniform veins are normally heat exchangers that aid in the thermoregulation of the testes, which is necessary for spermatogenesis. A varicocele upsets this balance and causes the testis to heat up to the normal core body temperature (37⁰C), whereas they are normally kept at 35⁰C.

There are several principles as to how varicocele affects the testis, but the major one shows that varicocele affects the testis by transporting warm blood from the abdomen to the testis in the scrotum. The testis functions best at 3 degrees below body temperature and warmer blood can impair its ability to produce sperm and testosterone.

Varicocele begins in puberty and grows over time. They are more commonly found on the left side of the scrotum and may be uncomfortable or painful, although they frequently have no symptoms or side effects. A varicocele may result in poor testicular growth, inadequate sperm production, poor sperm quality, decreased fertility and scrotal discomfort or other issues that could result in infertility.

CLASSIFICATION OF VARICOCELE

A varicocele is classified as either primary or secondary varicocele.

·       PRIMARY VARICOCELE

The majority of varicoceles is primary and is caused by incompetent or absent valves in the testicular vein (internal spermatic vein). The left testis is much more commonly affected (85%) than the right. This could be due to the right testicular vein’s shorter course which creates less back pressure. The left testicular vein, on the other hand, has a longer course and enters the left renal vein at a right angle. Bilateral varicoceles are common (15%), but isolated right varicoceles are uncommon and should be investigated for a secondary varicocele.

·       SECONDARY VARICOCELE

Secondary varicoceles are much less common and result from increased pressure in the testicular vein caused by compression such as renal mass, obstruction, or portal hypertension.

CAUSES OF VARICOCELE

Each testicle is supported by a spermatic cord. The veins, arteries, and nerves that support these glands are also found in the spermatic cord. One-way valves in healthy veins inside the scrotum transport blood from the testicles to the scrotum, where it is returned to the heart.

The cause of varicocele remains unknown but one possible contributing factor is the failure of valves inside veins that are supposed to keep blood flowing in the right direction. Furthermore, the left testicular vein takes a slightly different path than the right vein, increasing the likelihood of a blood flow problem on the left. When oxygen-depleted blood flows back up in the vein network and begins to pool in the vein, the veins widen (dilate), resulting in the varicocele.

SYMPTOMS OF VARICOCELE

A varicocele is most commonly found on the left side of the scrotum and often causes no symptoms. Some possible signs and symptoms include:

·       Pain – Standing may cause a dull, aching pain or discomfort and is frequently relieved by lying down.

·       Swollen scrotum – If the varicocele is large enough, it may appear as a “bag of worms” above the testicle. A smaller varicocele may be too small to see but may be felt.

·       Size of testicle – The affected testicle may appear to be significantly smaller than the normal healthy testicle.

·       Infertility – Although not all varicoceles can cause infertility. However, large varicocele can affect fertility negatively.

DIAGNOSIS OF VARICOCELE

Varicocele is diagnosed through a varicocele grading system. This system helps in characterizing the size of a varicocele in order to decide whether or not the varicocele present should be treated. Various systems have been developed, but the following is `the most widely used scale:

·       Grade 0 – this may be detectable on ultrasound but not physically detectable also known as “subclinical varicocele”.

·       Grade I – this is felt on physical examination when the patient performs a breathing technique that involves pinching the nose and breathing out forcefully with mouth closed (Valsalva Maneuver)

·       Grade II – this is felt on physical examination even in the absence of Valsalva Maneuver

·       Grade III – Varicocele causes visible scrotal deformity.

One important factor to consider is that larger varicoceles appear to have more negative effects. Large varicoceles are frequently visible with the naked eye, and patients may experience sensations looking like a “bag of worms” in their scrotum…………………………………TO BE CONTINUED