Sexually Transmitted Diseases - I. I. Mavrov 2005

Vascular Diseases of the Reproductive Organs
Varicocele

Varicocele is a nodular dilation of the Veins OF THE Spermatic Cord. It is characterized by elongation of the spermatic cord veins, accompanied by pain and a feeling of heaviness in the testicular region. The condition is relatively common, occurring in 6-10% of men aged 16 to 35, and typically manifests suddenly.

Etiology. Varicocele is rooted in factors that cause congestion in the pelvic Organs, such as constipation, irregular sexual activity, and heavy physical labor. The Development of the condition is also promoted by congenital weakness of the venous walls and Specific features of Blood outflow from the spermatic cord veins.

Patients frequently present with VARICOSE VEINS OF the lower extremities and hemorrhoids concurrently with a varicocele. This combination suggests that prolonged reduction of the cardinal Venous system may play a role in the onset of the disease. It is believed that varicocele extends beyond the narrow concept of impaired testicular function (N. A. Lopatkin, 1981), and should rather be viewed as a manifestation of renal venous Hypertension. The fact that the left testicular vein empties at a right angle into the left renal vein, while the right testicular vein empties at an acute angle into the INFERIOR VENA CAVA, explains why varicoceles occur much more frequently on the left side (80-90% of cases), as the outflow conditions from the left spermatic cord veins are less favorable than those on the right.

Clinical practice places great importance on so-called secondary varicocele—dilation of the spermatic cord veins resulting from impaired outflow from the pampiniform plexus caused by a pathological process in the pelvis or retroperitoneal space. Sometimes a varicocele, particularly on the right side, serves as one of the initial symptoms of a testicular tumor. Therefore, if the dilation of the spermatic cord veins is progressive, patients require a thorough examination.

Prevalence and Classification. According to various authors, varicocele occurs in 8-20% of men. Over the past decade, due to acceleration and early Puberty, varicocele among schoolchildren accounts for 8.8% (Yu. F. Isakov et al., 1977). Of concern is the fact that 20-80% of these patients exhibit impaired Spermatogenesis (A. V. Lyulko, 1965; K. A. Velikanov et al., 1973), which frequently progresses to impotence. Among individuals suffering from Infertility, 39% are found to have varicose veins of the spermatic cord (V. Stewart, V. Montie, 1973).

According to A. Z. Nechiporenko's classification (1964), there are three degrees of varicose dilation of the spermatic cord veins: grade 1 — dilated veins are detectable only by Palpation; grade 2 — dilated veins are detectable both by palpation and visually; grade 3 — varicosely dilated veins descend to the lower pole of the testicle.

Another classification (N. A. Lopatkin et al., 1981) is based on the degree of dilation (ectasia) of the pampiniform plexus veins and changes in testicular trophism: stage I — varicose vein dilation is detected only by palpation while the patient strains in an upright position; stage II — a clearly defined visual dilation of the veins is observed, but the size and consistency of the testicle remain unchanged; stage III — against the Background of pronounced dilation of the pampiniform plexus veins, There is a clear decrease in testicular turgor.

Clinical presentation. Varicocele is characterized by thickening of the spermatic cord and the presence of multiple tortuous veins within the Scrotum. The half of the scrotum where the varicocele is diagnosed appears lower. The clinical picture of the disease directly correlates with the size of the varicocele. In The First stage of the disease, symptoms are typically absent, and the pampiniform plexus of dilated veins along the entire length of the spermatic cord is discovered only during routine examinations or conscript screenings. In the horizontal position, the dilated veins collapse.

In A number of cases, the condition progresses to the Second Stage. The veins of the spermatic cord dilate into node-like clusters, extending below the upper pole of the testicle. On the affected side, the testicle drops, the tone of the cremaster Muscle noticeably decreases, and the corresponding half of the scrotum hangs down. Patients begin to report pain, the intensity of which can vary (ranging from a feeling of discomfort during walking and heaviness in the corresponding half of the scrotum after physical exertion, to severe neuralgia-like pain). Radiation of pain follows the entire innervation zone of the spermatic nerve. In some cases, patients experience excessive sweating and a burning sensation in the scrotum, alongside a decline in sexual function.

The Third Stage of varicocele presents a pronounced clinical picture. Severe pain in the enlarged half of the scrotum occurs not only during physical exertion, but also at rest and even at night, occasionally becoming unbearable. Palpation reveals a cluster of enlarged venous nodes that extend below the lower pole of the testicle when the patient is standing. The testicle itself is reduced in size and somewhat edematous. The cremasteric reflex is absent. Inflammatory Changes in the varicosely dilated veins are frequently observed.

Although the General condition of patients with varicocele is not significantly compromised in most cases, the disease steadily progresses and leads to impaired reproductive function and sexual disorders. The unusual sensitivity of the spermatogenic epithelium to adverse conditions in cases of varicocele (higher scrotal Temperature; venous congestion; hypoxemia; impaired nourishment resulting from the elongation of Arteries supplying the testicle and surrounding Tissues, narrowing of their lumen, and vasospasm; lymphostasis in the affected testicle; mechanical pressure on the testicle from varicosely dilated veins, etc.) makes it exceptionally vulnerable to damage.

Numerous studies have proven the presence of impaired spermatogenesis resulting from altered Blood Circulation and metabolic processes in the testicle. Over time, unilateral varicocele leads to morphological changes in the contralateral, seemingly unaffected testicle as well, which diminishes the fertilizing capacity of the sperm and can cause oligozoospermia, up to and including azoospermia. Therefore, if medical assistance is not provided in a timely manner, the pathogenic effects of varicocele persist, and spermatogenesis progressively deteriorates.

Diagnosis of the condition is relatively straightforward and is based on the palpation of the scrotal contents. The examination is performed with the patient in both upright and horizontal positions. The evaluation of patients with varicocele begins with inspection, during which the affected side, the degree and stage of the varicocele, and signs of testicular atrophy (decreased turgor, reduced size) are determined. In transient renal venous hypertension (resulting from Nephroptosis, renal vein entrapment, etc.), the varicocele will be pronounced only when the patient is standing. In persistent renal venous hypertension, resulting from organic stenosis of the renal vein, scarring processes in the surrounding adipose tissue, etc., the Filling of the pampiniform plexus veins is practically identical in both the horizontal and vertical positions of the patient.

The workup also includes plain radiography and excretory urography in both horizontal and vertical patient positions to detect nephroptosis, tumors, or renal anomalies. Right-sided varicocele may suggest the presence of a renal neoplasm, as can a varicocele on either side that does not disappear or diminish when the patient moves from the vertical to the horizontal position.

Laboratory studies include quantitative urine testing involving the collection of urine produced over 10-12 hours; determining the count of erythrocytes, leukocytes, and casts in it (Addis-Kakovsky method); establishing daily protein loss, etc. In married men, as well as in the presence of Complaints regarding infertility and impotence, semen analysis and the measurement of testosterone and pituitary hormone levels are mandatory. In cases of azoospermia, testicular biopsy is indicated to differentiate between secretory and excretory forms. The data obtained allow for the Assessment of the degree of renal-gonadal function impairment and can be significant in evaluating Treatment outcomes.

Treatment can be conservative or surgical. Conservative management includes: locally — cold compresses; internally — high doses of bromides, phenobarbital; subcutaneously — solutions of omnopon, morphine; ether anesthesia is used (short-term); novocain blockade and perfusion of the corpora cavernosa with a heparin solution yield good results. If conservative treatment proves ineffective and severe pain persists, surgical intervention is indicated and should be implemented in the Cytology/cytology/16.html">Early stages of the disease. There are numerous surgical techniques (over 50) for treating varicose veins of the spermatic cord. They can be conditionally divided into three groups: 1) excision of the spermatic cord veins; 2) surgery on the scrotum to elevate the testicle and thereby improve blood outflow from the venous plexus; 3) surgery on the coverings of the spermatic cord.

Prophylaxis. To reduce the dilation of the spermatic cord veins, eliminating pelvic congestion is sometimes sufficient (normalization of bowel movements, avoidance of prolonged physical exertion, regulation of sexual activity, elimination of alcohol, etc.). Engaging in sports, getting adequate rest, and taking Vitamins are also beneficial. As a result of such measures, venous dilation decreases in a number of cases, and the disease does not progress. Patients with varicocele should be advised against wearing a suspensory for extended periods, as this can lead to hyperthermia and the suppression of spermatogenesis.