Evolving Approach to the Varicocele

Morphometric study applied to testicular and epididymis hydatids torsion

Twisted testicular appendages had difficult differential diagnosis with testicular torsion. The objective of this paper is to evaluate the number, shape, size and determine the laterality pattern of the testicular and epididymal hydatids and evaluate the correlations between the length and width of the testicular and epididymal hydatids with testicular measurements. We analyzed 60 fixed cadavers and 16 patients with prostate cancer without previous hormonal treatment undergoing bilateral orchiectomy, totalizing 76 units and 152 testicles. In relation to the testicular appendices, we analyzed the following situations: absence of testicular and epididymis appendages, presence of a testicular appendix, presence of epididymis appendix, and presence of testicular and epididymis appendix. We measured the length, width and thickness of the testis and classified the appendages as sessile or pedicled. Chi-square test was used to verify associations between categorical variables. McNemar Test was used to verify differences between the percentages of right and left appendages. Correlations between quantitative measures were evaluated using the Pearson Correlation Coefficient (p < 0.05). In 50 cases (65.78%) we observed the presence of some type of appendices, in 34 cases (44.72%) we observed the presence of testicular appendices and in 19 cases (25%) the presence of epididymal appendices. We observed the presence of pedicled appendices in 39 cases (51.32%), with 25 of the cases (32.89%) of pedicled testicular appendices and 14 of the cases (18.42%) of pedicled epididymal appendages, with a significant association between the occurrence of appendices on the right and left sides (p < 0.001). Testicular hydatids were present in around two thirds of our sample being pedunculated in almost half of the cases with bilateral similarity. There is a significant chance in cases of twisted appendices that the same anatomical characteristics are present on the opposite side, which is a factor that tends to indicate the need for contralateral surgical exploration in cases of torsion, however studies with larger samples are needed to confirm these findings.

Increased intraoperative vein ligation in microsurgical varicocelectomy is associated with pain improvement

Varicocele is a major cause of male infertility. However, few studies have discussed the potential associations between the pain caused by varicocele and preoperative and intraoperative factors. The aim of this study was to evaluate factors potentially associated with changes in pain score after microsurgical varicocelectomy. This retrospective study was conducted between August 2020 and August 2022 at China Medical University Hospital in Taichung, Taiwan. Patient characteristics including age, body mass index, semen analysis, testicular volume, and the number of veins ligated were collected. Preoperative and intraoperative factors were analyzed to determine if they were correlated with changes in numeric rating scale (NRS) after microsurgical varicocelectomy. A total of 44 patients with clinical varicocele underwent subinguinal microsurgical varicocelectomy and were analyzed. The overall pain resolution rate was 91%, and the average satisfaction score after surgery was 9.2 according to their subjective feelings. Multivariate analysis revealed that severe varicocele grade (odds ratio [OR] 16.5, 95% confidence interval [CI] 3.01-90.47; P = .018) and the number of veins ligated (OR 6, 95% CI 1.6-22.48; P = .013), were significantly associated with changes in NRS after surgery. In addition, the area under the receiver operating characteristic curve for changes in NRS and the total number of veins ligated was 0.869. Microsurgical varicocelectomy had a high success rate for scrotal pain and satisfaction. Severe varicocele grade and the number of veins ligated in microsurgical varicocelectomy were associated with postoperative pain improvement.

Prediction of testicular atrophy based on sonographic findings immediately after successful manual detorsion

Purpose

To investigate and determine the sonographic findings obtained from manually distorted testes to predict testicular atrophy following manual detorsion.

Materials and methods

Twenty-two patients who had been diagnosed with testicular torsion and undergone manual detorsion were included. These patients were classified according to the presence or absence of testicular atrophy. The duration of symptoms, presence or absence of hyperperfusion within the entire affected testis, and echogenicity (homogeneous or heterogeneous) within the affected testis were compared using the Mann-Whitney U-test or Fisher's exact test, as appropriate.

Results

Testicular atrophy was detected in seven patients. There was a significant difference in the frequency of hyperperfusion within the entire affected testis (with atrophy [present/absent] vs. without atrophy [present/absent] = 0/7 vs. 8/7, P = 0.023) between patients with and without testicular atrophy. No significant differences in the duration of symptoms (with atrophy vs. without atrophy = 7 ± 3.3 h vs. 4.7 ± 3.6 h, P = 0.075) or frequency of echogenicity within the testis (with atrophy [heterogeneous/homogeneous] vs. without atrophy [heterogeneous/homogeneous] = 2/5 vs. 2/13, P = 0.565) were observed between the groups.

Conclusions

This small cohort study suggests that the presence of hyperperfusion within the entire affected testis immediately after successful manual detorsion is useful in predicting the avoidance of testicular atrophy.

Varicocele: An Endocrinological Perspective

Varicocele affects 15% of male population but it is more frequently identified in patients searching medical care for infertility. The impact of varicocele on semen production and fertility is known, but the relationship between clinical varicocele and impaired hormonal production is not clear. In published literature there are some studies regarding hormonal alterations in patients with varicocele but no review in which all the hormonal findings are explained. The aim of this review is to evaluate, by most common search engine, what is known about hormonal alterations in varicocele-bearing patients, to verify if a cause-effect relationship is documented and to give a useful contribution to in clinical management of this kind of patients. We found contradictory results about hormonal status from literature. Some studies confirmed a decrease of testosterone levels and higher FSH and LH levels that normalize after varicocelectomy, others found lower than normal levels of dihydrotestosterone due to decreased activity of epididymal 5-α-reductase. Lower circulating Anti-Müllerian Hormone levels, accompanied by a decreased Inhibin-B level, were reported as indicators of the decreased Sertoli cells function in varicocele-bearing adult patients. The finding of higher basal 17-OH-progesterone concentrations in patients with varicocele was explained by some authors with a testicular C-17,20-lyase deficiency. There is no doubt that varicocele could led to hormonal alterations. This review proposes that the impaired free sexual steroid levels are the result of a slight, deep-rooted defect in the testes of a certain amount of men with varicocele but further multicentre, randomized controlled studies remain mandatory to better clarify the hormonal features of patients with varicocele and to assess the utility of hormonal evaluation for establishing the duration of varicocele and for better identifying patients who need surgical correction.

Postvaricocele Embolization Pain Syndrome: A Case Series Report and Review of Current Treatment Strategies

BACKGROUND

Orchialgia is not an uncommon complaint among men with varicocele, but postvaricocele embolization-related testicular pain has not been widely investigated. This study evaluates the phenomenon of postvaricocele embolization pain (PVEP) syndrome and examines the current strategies to treat this unusual complication.

METHODS AND MATERIALS

A prospectively collected database of patients with PVEP who presented to a tertiary center was analyzed between January 2011 and January 2020 following internal ethics approval. Patient demographics, including other complications related to embolization, analgesic requirements, and pain scores (on a 10-point visual analog score), treatment strategies, Patient Global Impression of Improvement (PGI-I) score and overall satisfaction score (on a 5-point scale), were reviewed. All patients were reviewed for a minimum of 12 months.

RESULTS

A total of 20 men with a mean age of 33.8 (18-45) years old, presented with PVEP over 10 years. Most men received embolization on an average of 26.6 (18-48) months. The reasons for varicocele embolization include either isolated or combined orchialgia (15 men), subfertility (5 men), and cosmesis (6 men). Eighteen (90%) men underwent microscopic spermatic cord denervation (MSCD) and 2 patients elected for conservative measures. The average pain scores pre-MSCD and post-MSCD were 6.9 (4-9) and 1.4 (0-4) (p<0.001) with a significant reduction in analgesia requirements. Immediate improvement in pain score was reported in all the patients and this persisted at the 12 months review. Most men reported a high satisfaction score (of 4/5) and only one patient reported no change in symptoms after MSCD.

CONCLUSION

PVEP is a unique complication and patients should be counseled on the potential risk of persistent orchialgia following embolization for varicocele. The MSCD appears to be an effective treatment option with high success and satisfaction rates.

COVID-19 and varicocele: the possible overlap factors and the common therapeutic approaches

Varicocele is recognized as one of the main attributable causes of male infertility which can affect spermatogenesis by various pathophysiological mechanisms. Recent studies have identified oxidative stress and reduction in antioxidant, hyperthermia, hypoxia, hormonal dysfunction, and inflammatory conditions as major factors in the pathophysiology of varicocele, all of which have known direct associations with the coronavirus disease 2019 (COVID-19) and can significantly increase the risk of detrimental COVID-19-related outcomes. Emerging data have shown an association between COVID-19 and inflammation, overproduction of cytokine, and other pathophysiological processes. The present review, summarizes the current understanding of the pathophysiology of varicocele and investigates the potential correlation between the severity of COVID-19 and the varicocele disease. In addition, various possible treatments which can be effective in both diseases were examined. Despite numerous challenges associated with the prevalence of COVID-19 in healthcare systems in infected countries, special attention should be given to maintaining a high level of care for complex patients with a pre-existing disease such as varicocele and providing appropriate practical advice for optimal control of the COVID-19 disease. This article is protected by copyright. All rights reserved.

Treatment of subclinical varicocele with acupuncture: A case report

Varicocele is a vascular lesion characterized by abnormal dilatation and/or tortuosity of the veins of the pampiniform plexus, which sometimes manifests as chronic, dull pain in the scrotum, testicle or inguinal area. Subclinical varicocele (SCV) is as an early phase in the progression of its clinical analog. Given the lack of relevant studies on treatment strategies, no conclusive answer exists regarding how SCV should be managed. In this case report, a 40-year-old male patient visited our acupuncture outpatient clinic for left-sided scrotal pain and heaviness caused by SCV. After ten sessions of acupuncture treatments (acupuncture was performed at Zhongji (CV3), Guanyuan (CV4), qihai (CV6) and bilateral Guilai (ST29), Hegu (LI4), Taichong (LR3), Zusanli (ST36), Sanyinjiao (SP6), with electroacupuncture (EA) stimulation at Qihai (CV6) and Zhongji (CV3) as well as Guilai (ST29) on both sides), the patient was symptom-free. More unexpectedly, ultrasound reexamination showed no obvious abnormalities in bilateral spermatic veins. From this case, we conclude that acupuncture may be an effective alternative therapy for SCV treatment.

Disruption of anchoring junctions in the testes of experimental varicocele rats

Varicocele is a common disease of the male reproductive system and is the main cause of male infertility; however, the pathological mechanisms of varicocele remain unclear. The anchoring junctions (AJs) in the testies are located between Sertoli cells, or between Sertoli cells and germ cells. Intact and functional AJs are crucial for spermatogenesis. In the present study, the histomorphology, ultrastructure of AJ, cell cycle, expression of AJ structural proteins, and the level of AJ-associated signaling molecules were investigated in the left testes of experimental varicocele rats at 8 and 12 weeks after surgery. The results revealed that varicocele induced the loss of premature germ cells from the seminiferous epithelium. Furthermore, the results of the present study also revealed damage to the AJ ultrastructure, disorientation of the spermatid head, deregulation of the cell cycle, downregulation of AJ structural proteins, enhanced phosphorylation of focal adhesion kinase (FAK) at Tyr³⁹⁷ and its downstream adapter Src at Tyr⁴¹⁶, and activation of the extracellular signal-regulated protein kinase 1 (ERK1) signaling pathway. Thus, the present study demonstrated that varicocele disrupted the structure and function of AJs in the left testes of rats, and that enhancement of FAK phosphorylation may contribute to AJ damage by activating ERK1 signaling, disrupting actin-based filament networks, and altering the balance of the apical ectoplasmic specialization-blood testis barrier functional axis. These findings provide important insights into the pathological mechanisms through which varicocele contributes to male infertility and could help to identify new therapeutic targets for varicocele.

Varicocoele. Classification and pitfalls

Background

Varicocoeles have been considered for a long time potentially correctable causes for male infertility, even though the correlation of this condition with infertility and sperm damage is still debated.

Objective

To present a summary of the evidence evaluation for imaging varicocoeles, to underline the need for a standardized examination technique and for a unique classification, and to focus on pitfalls in image interpretation.

Methods

Based on the evidence of the literature, the current role of ultrasound (US) imaging for varicocoeles has been reported and illustrated, with emphasis on examination technique, classification, and pitfalls.

Results

US is the imaging modality of choice. It is widely used in Europe, while in other countries clinical classification of varicocoeles is considered sufficient to manage the patient. A number of US classifications exist for varicocoeles, in which the examinnation is performed in different ways.

Discussion

An effort toward standardization is mandatory, since lack of standardization contributes to the confusion of the available literature, and has a negative impact on the understanding of the role itself of imaging in patients with varicocoeles.

Conclusion

Use of the Sarteschi/Liguori classification for varicocoeles is recommended, since it is the most complete and widely used US scoring system available today.

Tubular extratesticular structures resembling varicocoeles, either at palpation or at US, should be identified and correctly characterized.

Conventional semen analysis and advanced sperm function tests in diagnosis and management of varicocele

Clinical varicoceles are a common cause of male infertility and affect sperm parameters as measured in a conventional semen analysis. Varicocelectomy has been shown in prospective studies to improve semen parameters in men with a clinical varicocele. Clinical varicoceles are also a well-known source of oxidative stress which may affect the quality of spermatozoa. Spermatozoa are particularly susceptible to oxidative stress due to a limited capacity for DNA repair. The susceptibility of spermatozoa to oxidative stress is modulated by a balance between ROS and antioxidants, which can be quantified by various laboratory assays. Varicocelectomy has been consistently shown to reduce both ROS and sperm DNA fragmentation, and various assays should be utilised in the diagnosis and treatment of infertile men with a clinical varicocele.

The use of scrotal ultrasound in the evaluation of varicoceles: A survey study of reproductive specialists

INTRODUCTION

Urologists use ultrasound in the male infertility workup to evaluate scrotal contents and objectively identify varicoceles if their presence is questionable on physical examination. We assessed practice patterns and diagnostic criteria of male reproductive urologists using ultrasound to evaluate varicoceles.

METHODS

An anonymous online survey was sent to the Society for Male Reproduction and Urology (SMRU) members. We queried respondents about ultrasonographic criteria and ultrasound techniques employed in varicocele evaluation. Chi-squared was used to determine association between categorical variables.

RESULTS

In total, 110/320 (34.4%) SMRU members responded. Sixty percent of respondents (66/110) reported performing scrotal ultrasound; 92.4 % (61/66) were attending urologists and 87.9% (58/66) completed an andrology fellowship. A total of 37.9% (25/66) performed their own ultrasound, while the remainder had ultrasound performed by an alternate practitioner. Among those performing their own ultrasound, 95.5% (21/22) measured varicocele venous diameter compared to 76% (29/38) when another practitioner performed the ultrasound. Venous diameter used to define a varicocele ranged from 2-4 mm. Although 80% (49/61) of respondents assessed retrograde flow during ultrasound, only 52.5% reported that retrograde flow was required for varicocele diagnosis. Almost all (60/61) indicated they would fix palpable varicoceles in patients with abnormal semen parameters. Fewer (42.6%, 26/61) respondents stated they would repair varicoceles found exclusively on ultrasound.

CONCLUSIONS

Ultrasound is commonly employed by male reproductive urologists to diagnose varicoceles. We identified that practitioners use various ultrasonographic criteria and techniques for varicocele diagnosis. Study limitations include recall bias and high degree of specialization among respondents.

Symptoms in Dilating Venous Disease

Lower extremity venous diseases or insufficiency include clinically deteriorating conditions with morphological and functional alterations of the venous system, including venous hypertension, vascular wall structural abnormality, and venous valvar incompetency in association with an inflammatory process. In fact, the same pathophysiological processes are the main underlying mechanisms of other venous insufficiencies in different vascular territories such as Peripheral Varicose Vein (PVV), varicocele, Pelvic Varicosities or Congestion Syndrome (PCS) and Hemorrhoidal Disease (HD). Regarding the anatomical continuity of lower extremity venous system, urogenital system (pampiniform plexus in male and broad ligament and ovarian veins in female) and anorectal venous system, it is reasonable to expect common symptoms such as pain, burning sensation, pruritis, swelling, which arise directly from the involved tissue itself. High coexistence rate of PVV, varicocele/PCS and HD between each other underlines not only the same vascular wall abnormality as an underlying etiology but also the existence of common symptoms originating from the involved tissue in dilating venous disease. Accordingly, it might be reasonable to query the common symptoms of venous dilating disease in other venous vascular regions in patients with complaints of any particular venous territory.

The prevalence and severity of varicocele in adult population over the age of forty years old: a cross-sectional study

Objectives: To investigate the prevalence and severity of varicocele in adult population over the age of 40. We also measured testicular size, consistency, and total testosterone levels with an aim to observe the effect of varicocele on testis as men age. Methods: Two hundred twenty-four patients with varicocele, 241 patients without varicocele who admitted to our clinic were enrolled in the study. We stratified participants by four age groups (40-49, 50-59, 60-69, >70 yr). Patients were grouped according to varicocele grade and laterality. The morning testosterone level was drawn. The subgroups were compared with each other. Results: Overall, varicocele prevalence was 48%. Of the patients, 104 had unilateral, 120 had bilateral varicocele. Of the patients with varicocele, 62 (13.30%) were found as grade 3, 99 (21.10%) were grade 2, and 63 (13.60%) were grade 1. The percentages of smaller testes in grade 1, grade 2, and grade 3 varicocele group were 20.60, 79.80, and 88.70 and a significant association was detected. Age stratification of the data revealed the smaller and soft testis prevalence as well as higher grade varicocele prevalance increased in older age groups. Conclusions: Varicocele presence is associated with lower testicular size, softer testicular consistency, and lower testosterone levels, especially in older patients with bilateral and high-grade varicocele.

Varicocele and Testicular Pain: A Review

Varicocele is the dilatation of the scrotal portion of pampiniform plexus and the internal spermatic venous system. About 15% of men suffer from scrotal varicocele and 2% to 10% of them complain of pain. The probable mechanisms for pain include compression of the surrounding neural fibers by the dilated venous complex, elevated testicular temperature, increased venous pressure, hypoxia, oxidative stress, hormonal imbalances, and the reflux of toxic metabolites of adrenal or renal origin. Testicular pain associated with varicoceles is typically described as a dull, aching, or throbbing pain in the testicle, scrotum, or groin; rarely, it can be acute, sharp, or stabbing. The management of testicular pain associated with varicocele starts with a conservative, non-surgical approach and a period of observation. Varicocelectomy in carefully selected candidates with clinically palpable varicocele resolves nearly 80% of all cases of testicular pain. Microsurgical techniques for varicocelectomy have gained popularity with minimal complication rates and favorable outcomes. The grade of varicocele, the nature and duration of pain, body mass index, prior conservative management, and the type of surgical method used, are predictors for the success of varicocelectomy.

Comparison of the clinical characteristics of patients with varicocele according to the presence or absence of scrotal pain

We investigated the clinical characteristics of patients with varicocele according to the presence or absence of scrotal pain. We retrospectively reviewed the records of patients who underwent varicocelectomy. The age, body mass index, grade, laterality of varicocele, testicular volume difference, time to hospital visit, serum testosterone level and semen parameters were evaluated. A total of 954 patients were included. The painful group had lower mean age, lower BMI, higher grade of varicocele, smaller testicular volume difference and shorter time to hospital visit than the painless group. In addition, the median serum total testosterone level and total sperm count, concentration and motility were higher in the painful group than in the painless group. In multivariate analysis, there were significant differences between the two groups in age, grade of varicocele, testis volume difference, time to hospital visit, total sperm count and concentration. Patients with painful varicocele visited hospital earlier because of the pain and tended to start treatment sooner. They were also younger, had smaller testis atrophy and had higher sperm concentration, even though they had a higher grade of varicocele than patients without pain. Although scrotal pain in varicocele patients is difficult to treat, it leads to early diagnosis and treatment.

Knowledge, Attitude and Practices Regarding Benign Testicular Disorders in the Educated Young Men of Pakistan

Background

It has been seen that despite the increasing incidence of benign testicular disorders (BTDs), little work has been done towards its awareness among the male populace. Also, the trend of not seeking help in this regard is concerning. In this study, we aim to better perceive the level of understanding and common practices regarding BTDs among educated young men.

Methods

A cross-sectional study was carried out among two groups of ages 14-20 and 21-28 years. The inclusion criterion was that of educated males in an urban setting. Data were collected through a standardized questionnaire using cluster sampling by independent interviewers. The questionnaire consisted of four parts dealing with demographics, knowledge, attitudes and practices. Chi-square and Mann-Whitney U test were used as the primary statistical tests.

Results

The sample population consisted of an equal number of participants between the ages of 14 and 20, and between 21 and 28 years (n = 200, 50%). About half the participants (n = 215, 53.8%) were not familiar with the term BTDs. The majority (n = 324, 78.8%) of participants were not aware of symptoms of BTDs. Three-fourth of the participants believed that the subject is considered taboo in Pakistan (n = 307, 73.6%) while a majority of participants (n = 340, 85%) believed media coverage can help spread awareness of BTDs. A huge number (n = 268, 67%) thought that BTDs can cause fertility problems while one-third of them would not perform testicular self-examination (TSE) in case of pain or swelling in the scrotal region (n = 119, 29.8). The level of education and age were significantly associated with the knowledge regarding symptoms and types of BTDs.

Conclusion

Knowledge of BTDs and practices of TSE in the young educated men of Karachi are alarmingly poor. Therefore, there is an urgent need to create awareness at all levels using different strategies and platforms.

A review of varicocele repair for pain

A dilation of the pampiniform venous plexus in the scrotum above the testicle, called a varicocele, affects approximately 15% of the general male population. While the majority is asymptomatic, pain results in up to 10% of cases of varicoceles. The pain associated with varicoceles is typically mild and is described as heavy, achy, or dull—and is usually isolated to the testicle or spermatic cord. Guidelines clearly recommend varicocele repair in males with varicoceles, infertility, and an abnormal semen analysis. While chronic, severe pain is an additional indication for repair, a careful evaluation to rule out other etiologies in addition to a period of conservative management are necessary prior to surgical treatment because of the high incidental prevalence of varicoceles in the general population. Several techniques for varicocele repair have been described, including retroperitoneal, laparoscopic, inguinal, and subinguinal. Additionally, recent adjuncts to improve visualization and identification of critical structures including the operating microscope and microvascular Doppler ultrasound have improved success and complication rates. With careful patient selection, outcomes of varicocele repair with regard to pain are excellent, with over 90% of patients experiencing symptomatic relief. After failure of conservative treatments, a varicocele associated with pain should be considered for repair, and the microsurgical subinguinal approach is the gold standard surgical treatment, offering excellent outcomes while minimizing risk of complications.

Effects of Morinda officinalis Polysaccharide on Experimental Varicocele Rats

Morinda officinalis is a traditional Chinese herbal medicine, which has been used to tonify the kidney and strengthen yang for a long time in China. In this study, the effects of M. officinalis Polysaccharide (MOP) on experimental varicocele adolescent rats were investigated. The result showed that varicocele destroyed the structure of the seminiferous epithelium and decreased the TJ protein expression (Occludin, Claudin-11, and ZO-1), testosterone (T) concentration in the left testicular tissue and serum, and serum levels of inhibin B (INHB), while increasing the levels of cytokines (TGF-β3 and TNF-α) in the left testicular tissue, as well as serum levels of gonadotropin-releasing hormone (GnRH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and antisperm antibody (AsAb). MOP repaired the damaged seminiferous epithelium and TJ and reduced the levels of cytokines (TGF-β3 and TNF-α) as well as serum levels of GnRH, FSH, LH, and AsAb, while upregulating TJ protein expression, T level in the left testicular tissue and serum, and serum INHB levels. In summary, we conclude that MOP promotes spermatogenesis and counteracts the varicocele-induced damage to the seminiferous epithelium and TJ, probably via decreasing cytokines (TGF-β3 and TNF-α) levels and regulating the abnormal sex hormones levels in experimental varicocele rats.

The varicocele: diagnostic dilemmas, therapeutic challenges and future perspectives

A varicocele is defined as the abnormal dilation of the internal testicular vein and pampiniform venus plexus within the spermatic cord. If a semen analysis is not obtained from the adolescent male, in the absence of other symptoms, the main clinical indication used by many urologists to recommend repair is testicular atrophy. The varicocele may result in testicular damage in some males causing testicular atrophy with impaired sperm production and decreased Leydig cell function, while in other males the varicocele may seemingly cause no ill effects. In adult men, varicoceles are frequently present and surgically correctable, yet the measurable benefits of surgical repair are slight according to a Cochrane review. While occurring more commonly in infertile men than fertile men, only 20% of men with a documented varicocele will suffer from fertility problems. Most varicoceles found in adolescents are detected during a routine medical examination, and it is difficult to predict which adolescent presenting with a varicocele will ultimately show diminished testicular function in adolescence or adulthood. As in adults, the mainstay of treatment for varicocele in adolescents is surgical correction. However, unlike an adult varicocelectomy (the microsurgical approach is the most common), treatment for an adolescent varicocele is more often laparoscopic. Nevertheless, the goals of treatment are the same in the adolescent and adult patients. Controversy remains as to which patients to treat, when to initiate the treatment, and what type of treatment is the best. This review will present the current understanding of the etiology, diagnosis and treatment of the adolescent varicocele.

Varicocele and testicular function

Testicular varicocele, a dilation of the veins of the pampiniform plexus thought to increase testicular temperature via venous congestion, is commonly associated with male infertility. Significant study has clarified the negative impact of varicocele on semen parameters and more recent work has shed light on its detrimental effects on the molecular and ultrastructural features of sperm and the testicular microenvironment, as well as more clearly defined the positive impacts of treatment on couples’ fertility. The relationship between varicocele and testicular endocrine function, while known for some time based on histologic evaluation, has become more apparent in the clinical setting with a growing link between varicocele and hypogonadism. Finally, in the pediatric setting, while future study will clarify the impact of varicocele on fertility and testicular function, recent work supports a parallel effect of varicocele in adolescents and adults, suggesting a re-evaluation of current treatment approaches in light of the progressive nature of the condition and potential increased risk of future disease.

Novel insights into the pathophysiology of varicocele and its association with reactive oxygen species and sperm DNA fragmentation

Varicocele has been associated with reduced male reproductive potential. With the advances in biomolecular techniques, it has been possible to better understand the mechanisms involved in testicular damage provoked by varicocele. Current evidence suggests the central role of reactive oxygen species (ROS) and the resultant oxidative stress (OS) in the pathogenesis of varicocele-associated male subfertility although the mechanisms have not yet been fully described and it is likely to be multifactorial. Excessive ROS is associated with sperm DNA fragmentation, which may mediate the clinical manifestation of poor sperm function and fertilization outcome related to varicocele. Testing of ROS/OS and DNA fragmentation has the potential to provide additional diagnostic and prognostic information compared to conventional semen analysis and may guide therapeutic management strategies in individual patient.

Randomised clinical trial of comparing effects of acupuncture and varicocelectomy on sperm parameters in infertile varicocele patients

The aim of the study was to evaluate the effect of the acupuncture treatment on sperm parameters and pregnancy rates in patients with primary infertility. Between January 2008 and May 2010, 30 men with the primary infertility (one year of unprotected intercourse, healthy wife) and varicocele with normal hormone levels and abnormal semen analysis were randomised into two groups. Group 1 underwent subinguinal microscopic varicocelectomy, and Group 2 underwent acupuncture treatment twice a week for 2 months. Both groups were evaluated with semen analysis at 6 months after the treatment. Patients in both groups evaluated with telephone calls and e-mail in terms of pregnancy. The mean age of the patients was 27.2, and groups were comparable regarding the age (P = 0.542). The pre-treatment sperm concentration, motility and morphological characteristics were similar in both groups. Sperm concentration and motility improved significantly in both groups after the treatment. Increase in sperm concentration was higher in the acupuncture group compared to the varicocelectomy group (P = 0.039). The average follow-up was 42 months, and pregnancy rates were emphasised 33% in both groups. Acupuncture treatment in primary infertile varicocele patients with semen abnormalities seems to be effective and has comparable results with the varicocelectomy treatment.

Males' Awareness of Benign Testicular Disorders: An Integrative Review

Disorders that affect the testes can range from painless and benign to debilitating and life threatening. Despite the availability of literature on the etiology, diagnosis, and treatment of benign testicular disorders (BTD), very little is known about men's awareness of these conditions. The aim of this review was to extract and analyze evidence from studies that explored males' awareness of BTD. Four e-databases (CINAHL, MEDLINE, PsychINFO, and PubMed) were thoroughly searched and four articles met the review inclusion criteria. The quality of the included studies was appraised and data were extracted and cross-checked using a standardized data extraction table. It was determined that participants lacked education about testicular self-examination and scrotal signs and symptoms which contributed to their lack of awareness of BTD. Help seeking in the event of scrotal abnormalities was suboptimal which is alarming given the acuteness of some BTD such as testicular torsion. Individuals who are at risk for health disparities were underrepresented in the reviewed literature. Findings from this review highlight the need to address barriers to BTD knowledge and help seeking. This could be achieved through making use of past interventions that succeeded in increasing men's awareness of testicular cancer such as university campaigns and mass media. From a practical standpoint, clinicians must be encouraged to educate young men about BTD. This could be attained through tailoring creative educational interventions that are sensitive to the needs of individuals who are at risk for health disparities.

Adolescent Varicoceles and Infertility

Varicoceles are associated with testicular atrophy and abnormal spermatogenesis. Varicocele-related testicular damage is thought to be progressive in nature. Adult varicoceles are common in men with infertility, and varicocele repair in this population has demonstrated improved semen parameters and paternity outcomes. However, without solid objective endpoints (reproducible semen analyses, paternity), the indications for adolescent varicocele repair remain controversial. Given the controversy surrounding adolescent varicocele management, it is not surprising that surveys of pediatric urologists have revealed a lack of consensus on diagnostic approaches, treatment decisions, and operative approaches.

Varicocele as a source of male infertility - current treatment techniques

To establish the extent of varicocele as the cause of infertility in men and compare the various techniques of treatment. We searched PubMed and the Cochrane Library database using varicocele, male infertility, varicocelectomy as keywords. Varicocele seems to be a growing problem considered to be one of the most common causes of male infertility in recent times. Nevertheless, its role remains unclear. The best treatment option seems to be microscopic surgery - the most effective and linked to rare surgical complications. But the greatest clinical problem remains the selection of patients to treat - recently it is believed that varicocelectomy is a possibly advisable option in patients with clinical varicocele and seminal parameter impairment [1]. More high-quality, multicenter, long-term randomized controlled trials (RCT's) are required to verify the findings.

Microsurgical varicocelectomy with transfixing of the difficult-to-isolate periarterial vein using microsutures

OBJECTIVE

To address difficulty in isolating the adhered periarterial vein in microsurgical subinguinal varicocelectomy, we introduced the transfixing microsuture method as well as to evaluate the impact of this technical modification on the surgical success of varicocele repair.

MATERIALS AND METHODS

We retrospectively evaluated 4 patients with a mean age of 31.5 years who underwent subinguinal varicocelectomy with transfixion of the difficult-to-isolate periarterial vein (a 9-0 transfixing microsuture was placed transversely through the periarterial vein as near to the adjacent border between the testicular artery and adherent vein as possible; then, it was knotted to nick or completely ligate the lumen.) The incidence of recurrence or persistence, postoperative hydrocele formation, sperm improvement, and symptom release was analyzed.

RESULTS

In 4 cases, the periarterial vein transfixing procedures were performed with a mean follow-up of 6 months. No postoperative recurrence or hydrocele was identified postoperatively. One patient reported no symptom improvement, but there was significant improvement in the symptoms and/or semen parameters in the other 3 patients. Postoperative ultrasonography evaluation revealed that there was no postoperative varicocele recurrence or persistence, no hydrocele formation, and no testicular atrophy.

CONCLUSION

When the adhered periarterial vein is difficult to isolate and ligate, transfixing the vein with a microsuture in microsurgical subinguinal varicocelectomy is a viable compromise that reduces the incidence of postoperative recurrence or persistence without serious complications.

Endovascular transcatheter embolization of recurrent postsurgical varicocele: anatomic reasons for surgical failure

BACKGROUND

Formation or pre-existence of collateral gonadal veins in varicocele patients has been reported as the main cause of surgical treatment failure.

PURPOSE

To describe venographic findings in patients with postsurgical recurrent varicoceles and to assess the efficacy of the following minimally invasive endovascular treatment.

MATERIAL AND METHODS

Thirty-three men with failed surgical treatment of left-sided varicocele were examined between 2006 and 2013, using retrograde venography to assess the anatomy of varicocele draining veins before the attempted transcatheter embolization. Anatomic variants of gonadal veins were categorized according to the classification modified for the purpose of the present study. 3% polidocanol was used as an embolic agent together with pushable fibered coils.

RESULTS

In 31 (93%) out of 33 patients venography demonstrated incompetence of the gonadal vein or veins draining varicoceles after failed surgical treatment. The most frequent venographic finding was gonadal vein duplication - 66% of cases (39% in its mid-portion). Technical success of embolization was achieved in all 31 patients. No major complications were observed.

CONCLUSION

Retrograde varicocele embolization may be superior to surgery because of its ability to detect gonadal vein variants. In our study group, transcatheter embolization with 3% polidocanol and fibered coils allowed successful, minimally invasive treatment of postsurgical varicoceles.

[The varicocele: the proper therapy for the proper patient]

Varicocele is present in 15% to 20% of the general population, but in approximately 35% to 40% of males presenting for an evaluation of their infertility. Indeed it is well known that varicocele can cause testicular damage and infertility. No evidence indicates a varicocele treatment in infertile men who have normal semen analysis or in men with subclinical varicocele. In this situation, varicocelectomy cannot be recommended. Varicocele repair may be effective in men with subnormal semen analysis, a clinical varicocele and otherwise unexplained infertility, but we need further randomized studies to confirm that this subgroup of infertile couples will benefit from treatment. There is no doubt about the standard indications of varicocelectomy, but recent literature seems to go towards new indications of varicocele repair. The aim of this review is to give a look at the literature to analyze the proper indications to varicocelectomy for the proper patient.

The effects of varicocelectomy on the patients with premature ejaculation

BACKGROUND

Premature ejaculation is one of the most problems in clinical practice. The association between varicocele and premature ejaculation was poorly understood. The effects of varicocelectomy on premature ejaculation in varicocele patient was studied.

OBJECTIVES

The aim of this study was to determine the impacts of varicocelectomy on patients with both premature ejaculation and varicoceles.

PATIENTS AND METHODS

This was a clinical trial study, conducted on 124 patients (20-35 years old), with varicoceles and premature ejaculation (PE), since March 2011 to April 2013. Inguinal and sub inguinal varicocelectomy were performed for them. All patients had both impairment of spermiogram and PE. These patients were followed up for about 2 years and evaluated for PE, in addition to parameters of spermiogram, before and after the surgery.

RESULTS

A total number of 124 patients with varicoceles and PE were enrolled into the study. Following the surgery 46 patients (37%) were fully treated (P < 0.001), 78 patients (63%) had improvements in PE symptoms changed to early ejaculation (P < 0.05) and 89 patients (72%) had improved parameters of spermiogram (P < 0.002).

CONCLUSIONS

In a significant number of patients who had clinical varicocele and not well responded to medical treatments for PE, varicocelectomy could effectively improve PE and spermiogram parameters.

Morphological changes in varicocele veins: ultrastructural study

BACKGROUND

Varicocele consists of dilatation of the pampiniform venous plexus and the internal spermatic veins. It is present in 15% of male population and is a common cause of male infertility.

OBJECTIVE

To describe the normal structure of the internal spermatic vein and the morphological changes in grade 3 varicocele.

METHODS

The authors dissected and analyzed a 2- to 3-cm tract of the pampiniform venous plexus of 20 patients undergoing varicocelectomy for left varicocele and of 10 consecutive patients undergoing surgery for left inguinal hernia. The histological examination was performed with hematoxylin–eosin and Masson trichrome stains. The ultrastructural evaluation was done using both scanning and transmission electron microscopy.

RESULTS

Compared with normal internal spermatic veins, varicocele veins showed narrowing and/or obliteration of the lumens, destruction of the endothelial cells, invagination of the intima, and deposition of collagen bundles in the media (light microscopy). The ultrastructural changes in varicocele veins included elongation of the endothelial cells with features of cellular damage, loss of the internal elastic lamina, and the appearance of ghost bodies and degenerative vacuoles in the subendothelial layer.

CONCLUSIONS

The authors believe this is the first report analyzing ultrastructual changes in normal human internal spermatic vein samples and in varicocele. The underlying molecular mechanisms of these changes await further studies.

Common scrotal and testicular problems

Scrotal and testicular problems range from the benign and painless to the malignant and debilitating. The primary care physician should be able to triage these problems and know when to give reassurance and when to initiate a targeted workup that may lead to specialist intervention. This article focuses on scrotal pain and palpable abnormalities. Scrotal pain includes well-defined acute causes such as torsion and infection and the less well-defined chronic orchialgia. Palpable abnormalities covered here include cryptorchidism, hydrocele, spermatocele, varicocele, and testicular cancer.

Pediatric robot-assisted laparoscopic varicocelectomy

PURPOSE

We determined the feasibility and safety of robot-assisted laparoscopic varicocelectomy (RALV) in the pediatric population compared with laparoscopic varicocelectomy (LV).

PATIENTS AND METHODS

We identified all patients who underwent RALV since April of 2006. For each case, we selected two age-matched controls who underwent LV and compared the groups in terms of operative times, postoperative complications, and hospital charges. Statistics were determined using the Student t test and the Fisher exact test.

RESULTS

Four patients underwent RALV with a mean age of 15.3 years (standard deviation 1.3). All varicoceles were left-sided. Two patients had testicular size discrepancy at presentation (mean 24%). Mean operative times were 112 minutes for RALV vs 73 minutes for LV (P = 0.02). No intraoperative or postoperative complications were experienced in the RALV group. The mean total hospital charge-including facility, equipment, anesthesiology, and recovery room fees, but excluding surgeon's professional fees-was significantly higher for the robot-assisted group ($15,800 vs $8,600, P = 0.0005).

CONCLUSION

We report the first RALV in a pediatric patient population. We demonstrate that it is technically feasible with no intraoperative complications. It remains to be seen whether RALV is cost effective over LV.