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Varicocele of the Testis (1/2)

• Varicocele (1/2): Classification, pathophysiology, signs and symptoms
• Varicocele (2/2): Treatment (Surgery)

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

• Subclinical: no evidence of a varicocele with inspection or palpation, but reflux is visible with Doppler ultrasound imaging.
• Grade I: not visible, palpable only with a Valsalva maneuver.
• Grade II: not visible, palpable without a Valsalva maneuver.
• Grade III: visible through the scrotum without a Valsalva maneuver

Epidemiology

Varicocele is common and in approximately 4–11% of adult males detectable by clinical examination. Approximately 90% of primary varicoceles are on the left side; right-sided varicoceles are usually less severe and only detectable by Doppler ultrasound imaging. A high BMI decreases the likelihood of varicocele (Rais et al., 2013). The prevalence is up to 30% when doppler sonography is used for varicocele diagnosis (ChancWalters et al., 2012). The clinical prevalence of varicocele in men with subfertility is 25% (Marmar et al., 2007).

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 decompensate. Collaterals develop to the internal and external iliac veins with disease progression.

Secondary Varicocele

Secondary varicoceles are caused by a retroperitoneal mass with compression of the internal spermatic vein. Another cause of secondary varicocele is the Nutcracker syndrome: compression of the left renal vein between the superior mesenteric artery and the aorta.

Pathophysiology of 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

A disturbed function of the germinal epithelium of the testis is the consequence of the above mentioned factors. Varicocele leads to microscopically visible impairment of Sertoli cell function, decreased inhibin secretion and thus an increase in FSH. The impaired blood supply impairs Leydig cell function, resulting in increased LH and sometimes decreased testosterone concentrations. Markers of subfertility are pathological parameters in the semen analysis (OAT syndrome) and increased DNA fragmentation of the spermatozoa.

Testicular Pathology due to varicocele

Gross Pathology:

Higher grade varicoceles lead to an atrophy of the testis.

Microscopic Pathology:

• Reduction of spermatogenesis with maturation arrest.
• Reduced Leydig cell number
• Tubular thickening and interstitial fibrosis
• In exceptional cases: Sertoli cell-only syndrome

Signs and Symptoms of a Varicocele

• Usually asymptomatic. Often incidental finding in routine examinations for male infertility.
• Palpable mass in the spermatic cord, increasing in upright position or with Valsalva maneuver.
• Scrotal pain, especially in upright position.
• Testicular atrophy: Normally the testes size varies not more than 20% or 2 ml in comparison to the other side.
• The primary varicocele is almost invariably on the left side. The right (and left) varicocele may be a symptom of a retroperitoneal tumor.

Diagnosis of a Varicocele

Scrotal Ultrasound with Doppler Examination

• Dilatated veins of the spermatic cord [Fig varicocele in ultrasound]? In adults, a venous diameter of more than 3.5 mm is abnormal.
• Reflux of blood during Valsalva maneuver [Fig varicocele in ultrasound]?
• Testicular size: difference of more than 20% or 2 ml?
• Testicular tumor?
• Renal and retroperitoneal ultrasound: Tumor?

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, teratozoospermia) is possible. Even non-obstructive azoospermia can be caused by a varicocele. DNA fragmentation of spermatozoa is increased. Grading of the varicocele correlates with markers of subfertility: for example, up to 55% of men with grade III varicocele have a pathological semen analysis (Damsgaard et al., 2016).

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.

References

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