Methods of Diagnostics and Treatment of of Varicocele

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Stoyanov
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Methods of Diagnostics and Treatment of of Varicocele

#1 Post by Stoyanov » 01 May 2018, 22:46

Methods of Diagnostics

Diagnostic measures for varicocele are palpation of the scrotum in the standing/lying position, evaluation of the consistency, and dimensional parameters of the testicles (through measurements, visually or using Prader ovals, etc.).
Additionally, the following measures can be taken:
• ultrasound with Doppler imaging to visualize the dilation of vascular flow back (the so-called reflux) in the patient's standing position or in the implementation of the Valsalva maneuver (with straining, respiratory arrest);
• scrotal thermography/thermometry (temperature difference between testes is determined);
• phlebography (filling veins with radiopaque material followed by X-ray examination).
When conducting a diagnostic examination for varicocele, it is possible to identify the presence and other associated pathologies:
• prostatitis – inflammatory lesion of the prostate (prostate gland);
• vesiculitis – inflammation of seminal vesicles;
• inflammation of the testicles (orchitis) or their appendages (epididymitis);
• urethritis – inflammatory diseases of the urethra;
• tumor formations, cysts, inguinal hernia, etc.
It is important to carry out a thorough differential diagnosis, because the following issues might be mistaken for varicocele:
• dropsy (excessive formation and accumulation of fluid in the tunic of testis);
• tumors of various types;
• epididymitis with chronic course;
• inflammatory lesion of the spermatic cord (funiculitis).
In vitro techniques also can be used:
• clinical urinalysis, because due to the increased pressure in the venous vessel, protein (proteinuria), erythrocytes (microhematuria) may be present in the urine as a result of certain diseases such as pyelonephritis (inflammatory process in the kidneys), urolithiasis, etc.;
• sperm analysis.

Methods of Diagnostics

Diagnostic measures for varicocele are palpation of the scrotum in the standing/lying position, evaluation of the consistency, and dimensional parameters of the testicles (through measurements, visually or using Prader ovals, etc.).

Additionally, the following measures can be taken:
• ultrasound with Doppler imaging to visualize the dilation of vascular flow back (the so-called reflux) in the patient's standing position or in the implementation of the Valsalva maneuver (with straining, respiratory arrest);
• scrotal thermography/thermometry (temperature difference between testes is determined);
• phlebography (filling veins with radiopaque material followed by X-ray examination).
When conducting a diagnostic examination for varicocele, it is possible to identify the presence and other associated pathologies:
• prostatitis – inflammatory lesion of the prostate (prostate gland);
• vesiculitis – inflammation of seminal vesicles;
• inflammation of the testicles (orchitis) or their appendages (epididymitis);
• urethritis – inflammatory diseases of the urethra;
• tumor formations, cysts, inguinal hernia, etc.

It is important to carry out a thorough differential diagnosis, because the following issues might be mistaken for varicocele:
• dropsy (excessive formation and accumulation of fluid in the tunic of testis);
• tumors of various types;
• epididymitis with chronic course;
• inflammatory lesion of the spermatic cord (funiculitis).

In vitro techniques also can be used:
• clinical urinalysis, because due to the increased pressure in the venous vessel, protein (proteinuria), erythrocytes (microhematuria) may be present in the urine as a result of certain diseases such as pyelonephritis (inflammatory process in the kidneys), urolithiasis, etc.;
• sperm analysis.

Treatment of Varicocele

The only effective method of therapy is surgical intervention. However, since the disease is not dangerous, the need for surgery is determined by a number of factors such as:
• orchalgia (pain in the testicles);
• testicular hypotrophy on the lesion side;
• male infertility;
• pronounced aesthetic discomfort.

At the same time, when identifying the pathology in children or adolescents, a number of specialists strongly recommend to perform a procedure to prevent the probable infertility. If the reduction in testes on the lesion side in adolescents has been proven, treatment is always required.

For men of reproductive age who plan to have children the following recommendations are provided:
• for the first degree (most episodes show no changes in the spermogram) – the operation is not indicated;
• for the second degree without changes in the spermogram – monitoring is recommended (semen examination every two years) and follow-up;
• for the second degree with changes in the spermogram – intervention is strongly advisable;
• for the third degree – almost always a surgery is required.
To date, there are many types of surgical interventions (over 120 techniques!) for the treatment of varicocele. Interventions can represent the operations of the following types:
• open;
• microsurgical (from a mini-access, or a small incision);
• laparoscopic, i.e. endoscopic procedure, when a mini-camera, clamp, scissors are introduced through three punctures (“advantages” – quick recovery, “disadvantages” – there is a risk of the disease-specific complications).

Depending on the zone to access the place of the lesion, the following operations are distinguished:
• subinguinal (Marmara, Goldstein) – accessed (through the incision) below the outer inguinal ring, using optical devices, can be performed on an outpatient basis, the recurrence of varicocele after surgery is minimal, as is the risk of developing dropsy (both problems occur in Marmara in approximately 2% of cases );
• inguinal (Ivanissevich) – accessed at the inguinal canal level, with general anesthesia; optical devices can be used as well, but relapse and complications are more common (but in children and adolescents the method is often preferable because of a thin artery that is difficult to see from the subinguinal access and low pressure);
• superinguinal (Palomo) – anesthesia is mandatory, the longest postoperative period, the risk of recurrence is slightly lower than in Ivanissevich's operation (however, on average the risk may reach 25%).

There are some other treatment options:
• microsurgical testicular revascularization, which implies the transplantation of the testicular vein to the epigastric vein to restore normal blood flow;
• endovascular techniques, which is embolization (blockage of the vessel with a special stopper) and sclerotherapy (administration of sclerosing drugs that stop the blood flow), etc.
In general, a physician will decide on the method of surgical intervention based on a number of factors (age of the patient, concomitant pathologies, the doctor’s experience accumulated in the field of a particular technique, etc.).

Success of surgical therapy determined by varicocele infertility depends on the below factors:
• age – the older the patient and the longer the disease and the degree of damage to the tissues, the lower the effectiveness;
• testicle volume – efficiency is lower if there is a significant decrease in volume due to the long-term varicocele;
• bilateral lesion (spermatozoa in the sperm may be completely absent, azoospermia);
• degree of development of pathology;
• content of the follicle stimulating hormone – in men this hormone indicates whether the lesion of the testicle is irreversible, therefore, at high values, the prognosis of treatment for the purpose of restoring spermatogenesis is disappointing.

Complications of the Disease

In isolation, varicocele is not a life-threatening pathology, but it can become a true cause of infertility. There are many theories explaining the development of such a complication:
• an increase in the temperature of the testes (due to the gradual stretching of the veins, the formation of a so-called “pillow”, and impairment of the temperature regulation of the scrotum) from 34 degrees, which is normal for this organ, to the body temperature suppressing normal sperm production (spermatogenesis);
• mechanical compression of the ducts by the affected veins;
• hypoxia (or, ischemia), low oxygen saturation of testicles due to the blood congestion;
• failure in supply of nutrients to the testicular tissues;
• flow of the active substances and hormones that have toxic effect on testicular tissue from the kidneys and r adrenal glands into the veins;
• development of an autoimmune process, when the testicles are not protected any longer, and the body attacks its own spermatozoa;
• decreased production of testosterone (male sex hormone).

Preventive Treatment

There is no a specific prophylaxis of varicocele, because the disease is caused by an anatomical/ genetic predisposition.

It is very important for young people to be timely examined by an andrologist or urologist and, if abnormalities are detected, they should be regularly observed or even treated.

If there is a varicocele at the initial stage, doctors recommend the following:
• avoid excessive physical loads;
• eliminate defecation issues;
• discontinue bad habits;
• have a regular sex life;
• ensure adequate rest;
• go in for sports (without excessive load).

In view of the possibility of developing a secondary varicocele, it is recommended that you regularly perform self-examination and visit a specialist from time to time. If this type of problem develops, it is necessary to identify and eliminate its root cause in a timely manner.

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