Etiology, diagnosis and classification of varicocele (Part 1)

Varicocele

Varicocele refers to the formation of localized veins in the pampiniform plexus of veins in the spermatic cord due to various reasons causing impaired blood return.

This condition is characterized by the dilation, tortuosity, and elongation of veins in the venous tract. Clinically, it can be divided into primary and secondary types.

This section primarily discusses primary varicocele. This condition mostly occurs on the left side, but can also occur on the right.

It can occur on one or both sides, often accompanied by testicular shrinkage, softening, and tissue changes, affecting the spermatogenic function of the testes and thus leading to spermatorrhea.

Fluid abnormalities can cause infertility in some cases, but some patients can recover their fertility after surgery and treatment with both traditional Chinese and Western medicine.

Educational ability.

Traditional Chinese medicine believes that varicocele is mainly caused by liver and kidney deficiency, malnourishment of the blood vessels, and disharmony of the meridians and qi.

It is caused by impaired blood flow and obstruction of the blood vessels in the scrotum.

**Western Medical Etiology and Pathology**

Varicocele can impair testicular spermatogenesis, leading to decreased sperm motility and count.

The sperm exhibits abnormal morphology, with an increased number of immature and pointed sperm. However, the pathogenesis of this disease remains inconclusive.

Some scholars have explained the occurrence of this disease using anatomical and hemodynamic theories, mainly including the following:

Points of view: ① Abnormal or absent valves in the spermatic vein. This is because the pressure in the renal vein is higher than that in the spermatic vein.

If the valves in the spermatic vein are abnormal, absent, or incompetent, it can lead to blood reflux, thus affecting the spermatic vein.

① The pampiniform plexus becomes congested and varicose. ② The left internal spermatic vein is longer and flows into the left renal vein; it is...

It connects to the left renal vein at a right angle. The left renal vein has high pressure, and the upright position of the body facilitates this return flow.

This makes the condition more difficult, which in turn leads to varicocele. ③ Lesions occur in the pampiniform plexus itself, leading to...

Decreased tension can lead to varicocele.

Varicocele, caused by various factors, initially leads to venous blood stasis in the testicles, which then...

Flow obstruction and increased arterial perfusion resistance lead to an imbalance in arterial perfusion. Furthermore, local ischemia causes the accumulation of metabolic products.

Under the influence of vasoactive substances or certain systemic factors, testicular microcirculation blood flow is redistributed, leading to...

This can lead to some lesions of the seminiferous tubules. Unilateral varicocele can occur through vascular anastomoses or the hypothalamus-pituitary axis.

The effects of factors such as the testicular axis or immune factors can influence the contralateral side, leading to bilateral hemodynamic changes.

Lateral testicular lesions.

In summary, the long-term presence of the underlying cause and microcirculatory disturbances creates a vicious cycle, while simultaneously affecting epididymal blood flow.

Circulatory disorders lead to structural and functional impairments of the epididymis, and varicocele further contributes to abnormal testicular temperature regulation.

Elevated testicular temperature can lead to impaired sperm development, and in severe cases, infertility. If not...

Even with timely treatment, the lesions persist for a long time, eventually leading to irreversible damage due to the injury to the basement membrane and vascular barrier of the seminiferous tubules.

Reverse infertility.

**Traditional Chinese Medicine Etiology and Pathogenesis**

This disease is caused by congenital deficiency, liver and kidney deficiency, and malnourishment of the meridians, leading to sluggish circulation of qi and blood; or by excessive...

Excessive fatigue, violent trauma; or stagnation of cold and dampness in the scrotum's veins, causing the veins to become tortuous and exposed.

Over time, testicular damage and impaired sperm production can lead to infertility.

**Key Points of Western Medicine Diagnosis**

**(I) Medical History and Clinical Manifestations**

Varicocele is more common in young adults. Mild cases usually have no obvious symptoms; severe cases may present with scrotal swelling.

Discomfort, dull or throbbing pain in the testicles, groin, and lower abdomen, often aggravated by prolonged standing or walking.

The pain is severe and can be relieved by lying down and resting. It is usually only discovered during a physical examination, and most patients experience symptoms in the scrotum.

Varicocele is often discovered during medical visits for pain or discomfort, or during examinations conducted for infertility. Some severe cases of varicocele are diagnosed as such.

Patients often experience fatigue, dizziness, weakness in the lower back and knees, insomnia, and even cold limbs and scrotal eczema.

Coldness, impotence, premature ejaculation, etc.

**(II) Physical Examination**

For mild cases, visual inspection and palpation combined with the Valsalva maneuver are effective methods for diagnosing clinical varicocele.

Method. The Valsalva test involves instructing the subject to close their mouth and nose tightly and forcefully hold their breath to increase abdominal pressure. If the subject remains still...

Increased scrotal dilation indicates a positive Valsalva test. In severe cases, scrotal skin laxity, elongation, and drooping may be observed.

The veins in the scrotum are tortuous, dilated, and clearly exposed. Palpation reveals a cluster of varicose veins resembling earthworms within the scrotum, similar to a sponge.

The varicose veins should feel similar to other veins. Applying pressure and lifting the vein can reduce their size, and they should disappear when lying flat. If they do not disappear, secondary varicose veins should be considered.

Varicocele requires further examination to confirm the diagnosis. Secondary varicocele is relatively rare and is mostly caused by abdominal pain.

Caused by diseases such as tumors in the bladder cavity, pelvis, or posterior bladder, as well as iliac vein obstruction.

**(III) Special Inspections**

(1) Semen examination: The semen showed a suppressed appearance, and the sperm cells were cone-shaped or irregular in shape.

An increase in immature sperm, decreased sperm motility, and reduced sperm count are observed. The most significant factor is the increase in immature sperm.

Frequent varicocele is a characteristic symptom of varicocele.

(2) Scrotal thermography: This method diagnoses varicocele by observing changes in testicular temperature.

The method is influenced by many external factors.

(3) Doppler ultrasound examination: can reveal whether there is reflux in varicocele.

(4) Isotope scrotal blood pool scan: This can reveal the blood supply to the testicular arteries and show the left and right sides of the scrotum.

Symmetry. Significant asymmetry indicates a positive result, slight asymmetry indicates a marginal result, and symmetry indicates a negative result. (Research...)

Studies have shown that this examination is valuable in diagnosing subclinical varicocele with suppressed semen changes.

(5) Spermatic vein angiography: This is currently considered the most reliable method, especially selective internal spermatic vein angiography.

The imaging results are excellent, allowing us to understand the presence and extent of varicocele. However, since this is an invasive procedure...

Sexual radiology is a diagnostic method with certain risks, so it is not used as a routine diagnostic method for varicocele.

**Western Medicine Diagnostic Criteria and Differential Diagnosis**

The diagnosis of varicocele relies on observation and palpation. Varicocele is generally classified into three degrees.

A positive Valsalva maneuver indicates grade I or mild varicocele; if the Valsalva maneuver is not required...

The test, that is, if the varicocele is palpable but not visible, indicates grade II or moderate; if standing, it can be...

Scrotal swelling and large, easily palpable varicocele indicate grade III or severe scrotum. Furthermore, clinical examination...

For clinical examinations, methods that cannot definitively diagnose subclinical varicocele include: ① scrotal thermography; ② multiple...

③ Ultrasound examination; ④ Isotope scrotal blood pool scan; ⑤ Spermatic vein angiography.

Varicocele should be clinically differentiated into primary and secondary types. Secondary varicocele is less common and is mostly caused by...

It can be caused by diseases such as tumors in the abdominal cavity, pelvis, and retroperitoneum, as well as iliac vein obstruction. Therefore, a clear diagnosis should be made clinically.

Avoid misdiagnosis.