Article 129: Grading, Examination, and Treatment of Varicocele

◇A Guide to Caring for Your Husband's Health as a Good Wife◇

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Treatment and recuperation of common diseases

Grading of varicocele

Clinically, varicocele can be divided into three degrees:

Grade 1 (mild): When standing, varicose veins are not visible on the scrotal skin, but varicose veins can be felt inside the scrotum. When lying down, the varicose veins disappear quickly.

Grade 2 (moderate): When standing, dilated veins can be seen protruding on the scrotum, and varicose veins can be felt inside the scrotum. The mass gradually disappears when lying down.

Grade 3 (severe): When standing, there are obvious large blood vessels on the surface of the scrotum, and obvious worm-like dilated veins inside the scrotum, with thickened and hardened vein walls; these disappear slowly when lying flat.

What tests should be done?

1. Doppler ultrasound examination: Reliable for diagnosing mild varicocele.

2. Isotope blood pool scanning: Generally only applicable to unilateral lesions.

3. Venography: This is an accurate and reliable method for diagnosing varicocele and its severity.

4. Semen analysis: Decreased sperm count, decreased sperm motility, or immature sperm development, increased number of pointed sperm, and in severe cases, azoospermia.

The impact of varicocele on fertility

From an anatomical perspective, the spermatic veins are the blood vessels that carry blood back from the testicles. They consist of the pampiniform plexus within the spermatic cord, which ascends to drain into the internal spermatic vein in the groin and finally into the renal vein. Blood flow is from bottom to top. When the valves in the veins are underdeveloped or malfunctioning, or when venous blood flow is obstructed, blood can stagnate or flow backward, causing the blood vessels in the spermatic cord to become engorged, thickened, and longer, resulting in varicocele. Because the symptoms are often subtle, many young men only discover they have varicocele during premarital checkups. Young men with varicocele often experience a feeling of heaviness or discomfort in the scrotum, with symptoms worsening when standing or walking and improving when lying down. Sometimes the pain can radiate to the groin and lower abdomen. After marriage, some may develop sexual dysfunctions such as premature ejaculation, although most patients experience no obvious symptoms.

When varicocele occurs, the backflow of blood, which is warmer than the scrotum, can impair spermatogenesis due to increased testicular temperature. Furthermore, during this retrograde flow, metabolic waste products from the renal and adrenal veins, such as steroids and catecholamines, reach the testicles and cause adverse effects. Additionally, the increased levels of prostaglandins and serotonin in the venous blood of patients with varicocele also affect sperm motility. Therefore, men with varicocele often experience infertility due to poor semen quality.

Varicocele accounts for approximately 30% to 40% of male infertility cases. Of course, not everyone with varicocele is infertile; the key factor is the degree of damage to the testicles. Some men with severe varicocele can still conceive, while others with mild cases are unable to conceive.

For male infertility patients, a thorough examination of the scrotum is necessary to determine the extent of varicose veins and the size of the testicles, and to ascertain whether surgical treatment is required. Approximately 50% to 80% of semen quality improves after surgery. Nearly half of the patients regain fertility after the procedure. Statistics show that the semen quality improvement rate through surgery exceeds 70%.

Which diseases should it be differentiated from?

1. Epididymal tuberculosis: Testicular soreness and dull pain, palpation reveals a mass in the epididymis, the spermatic cord may be nodular or beaded thickening, but the texture is relatively hard, the mass may rupture after several months and discharge clear, thin pus mixed with cottage cheese-like pus.

2. Inguinal hernia: This is caused by the contents of the abdominal cavity slipping into the scrotum. There is a reducible swelling in the scrotum, which is uncomfortable and feels heavy. The mass is round or pear-shaped when touched. There is an impact when coughing. The mass can be reduced back into the abdominal cavity when lying down and resting.

How does Western medicine treat this?

Mild varicocele without symptoms does not require treatment.

1. Non-surgical treatment: For mild varicocele or those with neurasthenia, scrotal support and cold compresses can be used.

2. Surgical treatment: For severe varicocele, sperm count below 20 million for three consecutive tests, or testicular atrophy; where the varicose veins disappear when lying down, high ligation of the internal spermatic vein can be performed. Surgical approaches include:

(1) High ligation of the internal spermatic vein via the inguinal canal: Similar to the hernia incision, the spermatic cord is exposed, the main trunk and branches of the internal spermatic vein are identified, and they are ligated. This surgical approach is simple and commonly used. Dilated external spermatic veins and testicular gubernaculum veins can be ligated simultaneously. If a surgical microscope is used during the operation, the effect is better, the recurrence rate is low, and there are fewer complications.

(2) Via iliac fossa: An oblique incision is made in the left lower abdomen, the peritoneum is pushed open, and the internal spermatic vein is located in the retroperitoneum and in front of the external iliac artery and ligated. The advantage is that if the internal spermatic artery is accidentally injured at this location, it will not cause testicular atrophy. The disadvantage is that the communicating branches cannot be treated at the same time.