Dr. med. Dirk Manski



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Varicocele of the Testis (1/2)

Review literature: (Bong and Koo, 2004) (Miller et al, 2002) (Rubenstein et al, 2004).

Varicocele: Definition and Classification

A varicocele is defined as ectatic and tortuous veins of the pampiniform plexus of the spermatic cord. Varicoceles are found in 15% of the male adolescents and may cause pain, damage to the testes and infertility.

Classification of Varicoceles

Etiology of Varicocele

Primary Varicoceles

The nearly perpendicular configuration of the renal vein with the left internal spermatic vein combined with incompetent venous valves leads to a long blood column with high pressure. The distal internal spermatic vein and pampiniform plexus become ectatic and further venous valves decompensate. The different configuration of the right internal spermatic vein with the vena cava prevents the reflux of blood and varicocele formation.

Two types of varicocele can be differentiated:

According to Dubin and Amelar (1970), varicoceles grade I are associated with the pressure type, varicoceles grade II and III are associated with the shunt type.

Secondary Varicocele

A retroperitoneal mass results in a flow impediment in the internal spermatic vein, which leads to a secondary varicocele.

Pathophysiology of the Testicular Dysfunction

Reflux of (Adrenal) Blood

Reflux of adrenal blood leads to the increase of norepinephrine in the varicocele and – by diffusion – in the testicular artery. This leads to a vasoconstriction in the testes.

Increased Testicular Temperature

Increased venous reflux of warm blood from the core of the body increases the temperature of the testis.

Elevated Venous Pressure

Venous reflux leads to an elevated venous pressure leading to a temperature increase and impairment of the testicular blood supply.

Dysfunction of the Testis

Reflux of adrenal metabolites, elevated testicular temperature, disturbed testicular perfusion and elevated venous pressure causes a dysfunction of the germinal epithelium. Signs are a microscopically visible impairment of the Sertoli cell function, decreased inhibin secretion and increased FSH concentration. The impairment of the testicular perfusion also affects the Leydig cell function with increased LH and normal to subnormal testosterone in patients with varicoceles. Abnormal hormone concentrations are often corrected with surgical therapy.

Testicular Pathology due to varicocele

Gross Pathology:

Higher grade varicoceles lead to an atrophy of the testes.

Microscopic Pathology:

Signs and Symptoms of a Varicocele

Diagnosis of a Varicocele

Scrotal Ultrasound with Doppler Examination

scrotal ultrasound of a varicocele with color Doppler

Scrotal ultrasound of a varicocele with color Doppler imaging: The left image shows ectatic veins in the spermatic cord. On the right: venous reflux with Valsalva maneuver.

Semen Analysis

A pathological semen analysis (oligozoospermia, asthenozoospermia) may be caused by a varicocele.

Laboratory tests:

An elevated FSH and low testosterone are typical for a testicular dysfunction due to a varicocele.

Scrotal Thermography

Experimental investigation. Scrotal thermography is vague and unspecific.







Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z



References

Bong und Koo 2004 BONG, G. W. ; KOO, H. P.:
The adolescent varicocele: to treat or not to treat.
In: Urol Clin North Am
31 (2004), Nr. 3, S. 509–15, ix

Evers und Collins 2004 EVERS, J. L. ; COLLINS, J. A.:
Surgery or embolisation for varicocele in subfertile men.
In: Cochrane Database Syst Rev
(2004), Nr. 3, S. CD000479

Dubin, L. und R. D. Amelar (1970). Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. In: Fertil Steril 21, S. 606–609.


Miller u.a. 2002 MILLER, J ; PFEIFFER, D ; SCHUMACHER, S ; TAUBER, R ; MüLLER, S. C. ; WEIDNER, W.:
Die Varicocele testis im Kindes- und Jugendalter.
In: Urologe
41 (2002), S. 68–77

Rubenstein u.a. 2004 RUBENSTEIN, R. A. ; DOGRA, V. S. ; SEFTEL, A. D. ; RESNICK, M. I.:
Benign intrascrotal lesions.
In: J Urol
171 (2004), Nr. 5, S. 1765–72


  Deutsche Version: Varikozele: Ursachen und Folgen