Sterility, varicocele among the first warning signs

Varicocele is a fairly common pathology that affects about 20% of males between the ages of 15 and 45

In most cases varicocele is asymptomatic and plays a clinical role due to the fact that it is the most frequent cause of male infertility

Studies show that varicocele is present in about half of all men who cannot have children.

It consists of dilatation of the veins of the pampiniform plexus, that is, the set of vessels from which the testicular vein originates.

The condition is more common on the left (95%) due to the right-angle outlet of the testicular vein into the ipsilateral renal vein.

This anatomical situation adds up, in predisposed individuals, to a decreased competence of the vascular system with progressive dilatation and venous reflux.

There is also a secondary varicocele, a consequence of any process occupying space in the retroperitoneum or in the pelvic cavity, capable of obliterating or compressing the testicular vein, the renal vein or the inferior cava, obstructing the venous outflow. In this case, involvement of the right testicle is also possible.

The venous damage described is reflected in testicular damage

Epidemiology shows that in about 35% of varicocele patients there are disturbances of spermatogenesis with possible development of pictures of reduced fertility.

The causes that may explain these pictures of hypofertility are still unknown.

One of the most accredited mechanisms is an increase in testicular temperature related to venous stasis.

Another theory identifies hypoxia, resulting from venous stasis, as the causal factor in the damage to spermatogenesis.

Varicocele is almost always asymptomatic, so the patient comes to the doctor’s attention due to the discovery of a slight scrotal swelling or for a male par tner’s assessment in the context of couple infertility.

Frequent is the occasional discovery, linked to population screening investigations, military visits or routine medical check-ups.

In the rare cases where symptoms are present, this is characterised by a gravitative pain with a sense of heaviness in the testicle, which is accentuated especially in a standing position, or after intense physical exertion.

The patient may perceive an elongation of the corresponding hemiscrotum, which appears to be occupied by a soft mass, varying with position, that evokes on palpation the sensation of a ‘vermicular’ skein.

The diagnosis of varicocele is rather simple and is based on a good inspection and palpation of the scrotum followed by subsequent ultrasound investigations.

On the basis of the objective examination, it is already possible to distinguish varicocele into three grades:

1st degree, or mild with venous ectasia only detectable on palpation when the patient performs the Valsalva manoeuvre (increase in abdominal pressure secondary to deep inhalation followed by forced exhalation with the glottis closed)

2nd degree, or moderate with palpable swelling, in orthostantism even without Valsalva manoeuvre, but not visible

3rd degree, or voluminous with ectasia already visible on inspection.

Definitive confirmation relies on ultrasound examination, which reveals venous dilatation of the pampiniform plexus and provides information on the location, volume, morphological characteristics and vascularisation of the testicles.

The ultrasound examination is a simple and non-invasive method, easily repeatable and therefore particularly suitable for studying the testicles.

With the aid of the echocolordoppler investigation, ultrasound also makes it possible to assess and quantify the degree of venous reflux both at rest and after the Valsalva manoeuvre.

In approximately 35% of varicocele carriers, there are disorders of spermatogenesis with the possible development of infertility.

As mentioned above, varicocele is recognised as the most frequent cause of male hypofertility.

In diagnostic terms, it is therefore essential to perform a spermiogram, i.e. analysis of the seminal fluid collected after 3-5 days of sexual abstinence.

The test, which must be repeated at least twice, is reliable only after the age of 16 and allows parameters such as ejaculate volume, seminal pH, concentration, motility and morphology of the spermatozoa to be defined.

A study of hormone status is also important because of the correlation between endocrinological status and testicular morpho-functional changes.

Hormonal diagnostics involves the dosage of certain hormones such as FSH, LH, Testosterone, Prolactin, Estradiol, Inhibin, thyroid hormones, SHBG.

According to the literature, early diagnosis associated with correct surgical correction allows an improvement in seminal parameters in 66% of patients with a 50% post-treatment pregnancy rate.

In childhood and adolescence, in the absence of a spermiogram reference, the surgical indication is related to the possible presence of testicular hypotrophy.

Any treatment of varicocele aims to preserve and improve the patient’s fertility

The treatment of varicocele is the surgical correction of venous reflux.

Surgical techniques make use of open surgery, laparoscopic surgery, and percutaneous scleroembolisation.

If the varicocele is asymptomatic and does not cause infertility, no type of therapy appears advisable, with the exception of a few behavioural precautions, such as the use of restraining briefs.

Recovery time after surgery is rather short with a normal resumption of daily activities after 24 hours.

Persistence of varicocele after surgery is not uncommon, with percentages ranging from 4 to 10%.

The next urological check-up must be carried out 6 months after surgery, after a spermiogram and ultrasound, in order to assess the effectiveness of the treatment performed.

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Source

Brugnoni

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