Varicocele are varicose veins in the testicles. It consists of abnormal dilatation of the testicular veins of the spermatic cord (which drain blood from the testicles), due to the difficulty in venous return.
THE incidence of varicocele varies with age, being 7.2% in individuals between 2 and 19 years (mean incidence for several age groups included in this interval), reaching 14.1% from 15 to 19 years. After age 20, the incidence ranges from 10 to 25%. When varicocele begins after age 40, it is essential to check for an intra-abdominal tumor that is tightening and dilating the testicular vein.
It is the most common treatable primary cause of male infertility. It is a common disease in first degree relatives of varicocele patients and tends to be more frequent in people with low BMI (inverse relationship between BMI and incidence). In most cases, varicocele occurs on the left side of the scrotal sac, affecting the left testicle, due to the characteristic anatomy of the man, in which the right testicular vein empties into the calibrous vein cava at a 45º angle and the left testicular vein drains to the left renal vein, of smaller caliber, and with a 90º angulation, which hinders the flow of blood.
It is important to emphasize, however, that varicocele does not indicate sterility, that is, absolute impossibility of having children. Many men with varicocele, especially in milder degrees, may have children normally without having to resort to artificial insemination or other approaches.
At causes of varicocele may be diverse, including absence or congenital incompetence of internal spermatic vein valves and difficulty in venous drainage through obstruction or compression of the venous system. There is a change in spermatogenesis, with decreased fertility by oligospermia (lower number of spermatozoa) and changes in the morphology (shape) of spermatozoa, leading to decreased motility. The reasons for these changes have not yet been elucidated, but it is believed that they may include hyperthermia (increased temperature in the scrotal sac - spermatogenesis should occur at lower temperatures, around 35 °), hypoxia (decreased oxygen in the testicles ), decreased intratesticular and epididymal blood flow, intratesticular hormonal changes, oxidative stress, and reflux of renal and adrenal metabolites.
The symptoms include pruritus (itching), pain, weight or discomfort in the scrotal pocket, but it is usually asymptomatic. also it's not common in the presence of erectile dysfunction (impotence), only in cases of bilateral varicocele and grade III, rare (see degrees below). In cases of greater severity, if the treatment is not done, the testicles may atrophy, with the reduction of testosterone production, which often causes impotence. Symptoms are aggravated when the patient is standing because blood drainage becomes difficult or when he makes physical exertions, especially when he contracts the muscles of the abdomen.
O diagnosis is done through the physical examination, with the patient standing orthostatically standing and examined in a warm room, ideally, but has a sensitivity and specificity of only 70%. You can do the self-exam, looking for palpable or visible varicose veins, but ideally you should check with a urologist. There is a graduation of varicocele, for those diagnosed with physical examination (clinical varicocele):
- Grade I - Small varicocele, being palpable only with increased abdominal pressure. (coughing or blowing against a resistance - "Valsalva maneuver");
- Grade II - palpable varicose veins without the Valsalva maneuver;
- Grade III - varicose veins visible through the skin of the scrotum.
The gold-standard complementary exam for the diagnosis of venous reflux in the pampiniform plexus (clinical and subclinical varicocele) is the venography of the spermatic vein. Color Doppler ultrasonography, scrotal thermography, and scintigraphy may also be performed.
O treatment of varicocele is indicated in those with symptoms (severe itching, pain, major swelling), infertility or signs of testicle atrophy. Older men who have no symptoms and no longer want to have children do not need to be operated on.
There are two options for varicocele correction:
- Surgical ligation The subinguinal pathway with optical magnification increases the likelihood of preservation of the arterial and lymphatic vessels, significantly reducing the risk of recurrence of varicocele in relation to laparoscopy and surgeries. The varicose veins can be performed in several ways: retroperitoneal, inguinal, subinguinal or laparoscopic. without magnification). It is done rapidly (45 minutes on average) with general anesthesia, and the patient is discharged within one to two days, but should avoid physical exertion for two to four weeks and intercourse for ten days.
- Percutaneous Embolization (internal spermatic vein occlusion - is associated with recurrence rates higher than conventional surgical methods, in addition to complications related to the method).
Correction of varicocele improves the spermogram and corrects infertility in 50% of cases (degree of evidence B). The chances of a conventional pregnancy can increase up to 2.8 times after the surgical treatment. However, infertility may be multifactorial, which makes the correction of varicocele in some patients only attenuate the problem, without solving it completely.
Varicocele is not a serious disease, and if treated properly and at the right time, it does not have major consequences. However, if a varicocele is suspected, a urologist should be consulted for evaluation and correct treatment if necessary.
