Varikotsele - a disease characterized by the expansion of the venous rete testis.Varicocele can be congenital or caused by a primary factor.Note that varicocele in men is quite severe disease and can, if not treated, lead to a complete sterility. It is because of circulatory disorders contributes to atrophy of testicular tissue, and interferes with normal spermatogenesis.
The most common is primary or innate varicocele.In addition most of the manifestation of varicocele is exposed left testicle.This can be explained by the fact that Vienna left testicle is longer than the right, and there is much greater pressure gradient.Therefore, varicocele easier to develop here, using a favorable basis.
main pathogenesis of varicocele is that venous rete testis occurs venous stasis.This stagnation can be formed due to three main reasons: lack of venous valves, veins insolvency and high pressure inside the veins, which prevents the promotion of blood through the veins
testicular vein as all the vessels of the body are in the structure of education-specific valves.These valves consist of several flaps and are closed during diastole of the heart, not allowing blood to rush backwards under the action of gravity.In addition valves coordinate all blood flow, giving it a purposeful movement.Under certain conditions (congenital or valvular insufficiency) flap valves sag under the bloodstream and passed it back.As a result, in some areas of veins accumulates a certain amount of blood.Over time, this volume is gradually increased, stretching the vessels.Veins have thinner wall compared with arteries and therefore stretched very quickly by undergoing deformation of the structure and leading to the development of varicocele.
in insolvency muscle venous layer vein simply can not pump a normal amount of blood on, so they again gradually accumulated volume of venous blood.Gradually stretch the veins entail valves and flaps, which can not link up.As a result, develop secondary failure, and even more will increase the inflow and accumulation of stagnant blood, which again will lead to the development of varicocele.
High pressure in the spermatic veins is similar to the insufficiency of the venous wall, the mechanism of the genesis of varicocele.High blood pressure prevents the promotion of blood on her bed in the normal function of the muscle wall of the vein.As a result, they will develop all the above mechanisms and varicocele.
In addition, the expansion of the walls of veins, high blood pressure and constant stagnation of blood activates the auxiliary system of veins.They are called venous collaterals, and act in an "bypass" - the creation of other ways in which the blood can flow away stagnant, so there is a lot in the egg "detours" anastomoses and shunts.But since these veins are even thinner wall than the main veins, they quickly stretched and around the egg formed multiple foci of congestion, which greatly exacerbates the varicocele.
causes leading to such pathogenic changes vary depending on the forms and types of varicocele.As mentioned above there is a varicocele and primary and secondary.Primary varicocele - especially congenital abnormality, which will be fully formed only at the end of their male sexual development.
reasons primarily due to varicocele different.This may be due to the failure of venous valves and veins testicular reverse casting the blood with a total diastole of the heart.Also varicocele can develop congenital muscular layer of the thin veins which simply can not push himself through the normal amount of blood.Another reason for this congenital pathology - is the location of the abnormal testicular artery that can thrown through the testicular vein and squeeze it, causing hypertension and subsequently lead to the development of varicocele.
Another important etiological feature varicocele is an intensive growth of boys in their teens.Thanks to this special wreath of veins in the testicle (acinar plexus) grows significantly intravascular pressure gradient.Also at this time enhanced arterial flow eggs and, as a result of the outflow of large amounts of blood, testicular vein is gradually stretched.At considerable tension veins and their valves can not perform its function of protecting blood vessels from the reverse (retrograde) blood flow.This is because the walls of the vessels dilate and the cusps simply can not close around.
Secondary varicocele is already apparent in adulthood.Most often it is due to the high intravascular pressure in the veins of the testicle or compression of the testicular vein, including the voluminous process (tumor).Secondary varicocele can cause renal hypertension, renal tumor formation and Hernia formation.
symptoms of varicocele
Basically varicocele is a slow and lengthy nature of the flow.Varicocele can as be accompanied by clinical symptoms of bright and not show them at all.In this second, "painless" disease course men can go for years with varicocele and did not even know of its existence.The most common such disease is detected at routine inspections and quite by accident.Incidentally random identification of varicocele medical staff at prophylactic examinations or treatment of other diseases quite common.
But apart from its asymptomatic, varicocele can also be accompanied by a number of its clinical manifestations.The first clinical evidence of varicocele, of course, is a pain.It can be quite different nature: stabbing, pulling or dull.Locate the more often it will be just in the testis and may be accompanied by unpleasant "burning" sensation.
pain varicocele increases with physical activity, sexual intercourse or constipation.Also, the pain may be aggravated by walking in a hot season.Reduces or even completely take place for some time, this pain can be in the horizontal position of the patient or raising the scrotum.This is explained by the fact that these provisions favor the outflow of stagnant blood from the affected testicle.It is also characterized by irradiation of pain in the lower back, abdomen, perineal area, hip and sometimes the penis.
character is also the progressive nature of the pain of varicocele: first, it is almost there, and there are only certain rare and discomfort.Then the pain occurs during exercise and in contact with the affected scrotal skin and tissue during walking but disappears at positions that promote blood flow.Finally, the pain will be permanent: they will bother the man always and everywhere, not cropped and enhanced the position of facilitating alone.
Interestingly, there are a few key points in the behavior of the patient, which can also speak about the possible presence of a varicocele.The patient will not be able to note a clear localization of pain in the scrotum.It will mark the relief for self relieving pain: wearing tight trunks or permanently sticking to the scrotum.
second major symptom of varicocele is the gradual development of sexual dysfunction and the emergence of reproductive dysfunction (negative attempts to conceive a child, which lasts for several years).These symptoms can be added voiding dysfunction: the day will celebrate these patients frequent urination at night may appear mandatory (involuntary) urge to urinate.
addition, varicocele, like other diseases, manifest common symptoms: fatigue, loss of appetite, feeling of "weakness" and reducing disability.
diagnosis of varicocele
To identify varicocele and direct the patient to follow-up treatment, there are a number of diagnostic methods.These methods can be both instrumental (ultrasound), and carried out with the help of certain samples (sample "straining" Valsalva) or visual (visible enlargement of the scrotum).
Physical signs can detect asymmetric enlargement of the scrotum by the affected testicle.If palpation reveals a decrease in eggs and increase its density, and much palpable varicose veins, it is a sign already begun a gradual atrophy of the testicle due to a varicocele.It is important to understand that the reduction in testicular atrophy is a sign of his varicocele only when it is asymmetric and accompanied by an increase in density.
Another important aspect of the scrotal palpation to determine the presence or absence of the patient varicocele, is that the palm of the physician and the temperature of the room, where he conducted research, should be at room temperature.Needless to cold hands doctor or cold room air will reduce muscle raises and lowers the egg and reduce the skin of the scrotum, which greatly complicate further the study.
specific probe to detect a varicocele is to conduct tests "straining" Valsalva.The patient is asked to hold your breath as much as possible while straining abdominal muscles.During this short time in the body significantly increases the level of intra-abdominal pressure.Such an increase in intra-abdominal pressure is the "indicator" to identify testicular varicose veins changed: if there are any, then during this trial they certainly can be found through visual inspection and palpation of the scrotum.
second probe specific for the diagnosis of varicocele is that in the upright position of the patient affected by varicose veins acinar eggs grow and expand.When you change the vertical position to horizontal, these veins decreases rapidly.
Another ruse is particularly palpation of the veins in varicocele.If these veins stroking downward, they are emptied and reduced in size.If, on the contrary, stroking them from the bottom up, you can easily fill up their blood, which will be accompanied by a significant expansion.
Among the instrumental methods widely used definition of varicocele Doppler testicular vasculature.When varicoceles in these vessels is marked venous-return throw.It is also possible to add the study while conducting sample "straining" and define a sharp increase in the diameter of the affected veins of about 0.5 mm or more.Besides using Doppler varicocele can be found at the inguinal rings of three or more extended spermatic vein, which will have a diameter of 3 millimeters.
addition testicular blood flow study advisable to semen analysis.In this analysis, with the possible varicocele, a special focus is on the performance of sperm motility.In the absence of movement or immobility should consider gradual atrophy of the testicle and varicocele.
varicocele is purely surgical pathology and should be treated surgically.In addition, no such thing as a "treatment of varicocele without surgery" simply does not exist.Only the performance of surgical aids can correct varicose veins in varicocele.
Surgical treatment is the key to treatment of varicocele.Drug therapy is also related to surgical treatment, and is used more often after surgery than before.The main groups of drugs to be used are vitamins, nutritional supplements with selenium and zinc, and optionally gormonosoderzhaschie (androgensoderzhaschie) preparations.The main purpose of this therapy - starting and maintaining a normal spermatogenesis in the postoperative period.Also, when severe pain in the first days after the surgery the patient can be administered NSAIDs to reduce pain and discomforts.
varicocele treatment before surgery is that the patient is carried out a number of procedures and studies aimed at unloading the body before surgery and the study of its general condition.Patients received blood biochemical studies on the level of urea and creatinine to assess renal function.Also held a general blood test to determine the level of hemoglobin, red blood cells and white blood cell count, and leukocyte count formula (it changes can talk about the presence of inflammation in the body, which is unfavorable for the operation).Also determined the blood group and Rh factor, it is necessary for the rapid transfusion of blood with massive intraoperative blood loss.It is also necessary to conduct tests for sensitivity to a particular type of anesthesia, in order to prevent allergy development on them and anaphylaxis in a patient during surgery.
Before surgery the patient sits on a special diet.On the day of the operational benefits the patient cannulated urinary catheter for continuous monitoring of urine output during surgery.
important to know that varicocele is a disease with a fairly good prognosis.The main thing here - as early as possible to appoint the treatment of the disease.
Operation testicular varicocele is indicated for clinical symptoms of the disease (especially when pain attacks), and occurs repeatedly (recurrent) varicocele and infertile marriages, to determine the effect of varicocele on the disruption of spermatogenesis in men.In addition, diagnostic features identified in favor of progressive atrophic changes eggs (size reduction and compaction of the structure) in the presence of varicocele is also a direct indication to perform a surgical benefits.
The essence of all operations varicocele - is the elimination of stagnation of blood in the veins of the testicle and correction of varicose veins of the testicle.Therefore, surgery to correct varicoceles are divided into the following types: operations that retain anastomoses and collaterals in the testis and operations aimed at the destruction of anastomoses.Now it is used a second type of surgery.The most popular of these are currently the two operational benefits: Ivanissevich operation and the operation of Marmara.
Surgery for Ivanissevich is more radical - if it is done ovarian vein ligation and used to access the retroperitoneal space.It can be carried out at a varicocele of any size, as well as for recurrent varicocele.This surgical manual begins with a broad section of the abdominal wall in the left iliac region.Thereafter, access is generated in the retroperitoneal space.Then released ovarian Vienna clamped two clamps ligated and crossed in the middle.In addition to the primary ovarian vein also found and removed in the same way all of its branches.After this is done out of layered operating field Staple the edges of the wound and applying a wide sterile dressing.
But now, this method is less effective, and after holding it at about 40-45% of patients develop repeated varicocele.This is due to the fact that not all branches of the testicular artery cross can be removed, the more access surgeon will see only a small part of them.As a result, some pathologically altered and expanded branches remain intact, helping to re-develop a varicocele.In addition, this operation is very traumatic, because when accessing incised skin, subcutaneous fat, muscle and other subject layers.As a result, the patient will need more long-term post-operative care, which together with the relatively high inefficiency of operations are not comfortable lying.
Another and more comfortable in a modern way, which is carried out in varicocele surgery is a method of Marmara.