VARICOCELE

A. Definition
A varicocele is an abnormal dilation of the veins within the spermatic cord or
within scrotum. These veins are called pampiniform flexus. The veins become
swollen.
B. Anatomy
- Testicle will produce testoterone hormone which is important for sperm
-

production, mucle strentgh and sex drive.

The scrotum is a skin-covered sac that holds testicles.
Scrotum makes the testicle cool enough for producing sperm.
Spermatic cord : cylindrical structure which contains blood vessels, nerves,
lymphatic, and vas deferens.
Vas deferens : sperm tube which connect epididymis to seminal vesicle.
Blood vessels :
o Testicular arteries
: Bring blood to the testicle
o Veins (pampiniform flexus) : Bring blood outside the testicle
o Vas deferens vein (smaller than pampiniform plexus) also bring
blood outside the testicle.
o From the pampiniform flexus blood flows to testicular veins.
Valve (inside the testicular veins) : prevent blood flows back to the testicles.

C. Etiology
1. Varicocele is the result of anatomical differences between the right and
left spermatic vein.
- The right testicular vein inferior vena cava (largest vein) at an acute
angle

The left testicular vein (longer than the right testicular vein) left
renal vein at a right angle.
It is believed that this disparity leads to an increase in the hydrostatic
pressure of the left spermatic vein, which is subsequently transferred

to the venous plexus causing its dilation.

2. Based on the observation that spermatic veins lack functional valves,
which can lead to regression of blood (reflux) .
3. There is a partial obstruction of the left spermatic vein due to the
compression of the left renal vein between the aorta and the upper
mesenteric artery (the nutcracker phenomenon).

D. Impact
The accumulation of blood in varicocele raise the temperature and reduce the
ability to produce sperm infertility.
Decrease the testosterone decrease energy and muscle strength sexual
problem.
Cause testicular pain.
E. Grading
Varicocele can be categorized as:
1. First grade: enlargement is evident only by palpation during the Valsalva
maneuvre (exhalation).
2. Second grade: enlargement is evident only by palpation at upright
position.
3. Third grade: enlargement of the venous plexus of spermatic tone is visually
evident
F. Who gets varicoceles
- Onset in adolescents 10-19 years old.

15% of young adult men.

G. How to diagnose
- Medical interview
e.g : sexual intercourse (frequency, timing), history of disease, free sex, etc.
- Physical examination
Varicoceles can be graded based on whether they are present in the standing
-

position.
Semen analysis
eg. : volume, liquefaction, sperm morphology, sperm motility, sperm count,

sperm concentration.
Ultrasonography (USG)
Hormonal assay
eg. : FSH, LH, Testosteron, estradiol

H. Management
- Surgery
1. Varicocelectomy
Varicocelectomy adalah ligasi atau pengikatan dari vena yang
mengalami dilatasi (varicocele). Biasanya terutama dilakukan pada
varicocele yang sudah mencapai grade II atau III. Vena yang dipotong
bertujuan untuk mengalirkan darah vena ke pembuluh vena yang lain
yang tidak mengalami varicocele (vas deferens vein).
2. Laparoscopic
Under general anaesthesia, three small incisions (5mm each) are made
in the abdomen. Varicoceles on the right or left or both can be
approached. The abnormal veins are identified and clipped.

Non-surgery
1. Embolization
A small puncture is made at the groin skin. A fine catheter is passed into
the underlying vein and followed into the testicular vein.

An x-ray dye is injected to map out where the problem is and where to
embolize or block. By using coils or balloons, blood flow to the
varicosed veins is blocked and is re-directed to other healthy pathways.