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Goubaa Mohamed MD Djerba Tunisia

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This is a 47-year-old male with vague scrotal discomfort and infertility. An ultrasound evaluation of the scrotum was performed with duplex Doppler evaluation. Color Doppler without and then with Valsalva maneuver was also performed. Ce Patient, âgé de 47 ans, se présente pour une gêne scrotale et une infertilité. Une échographie doppler couleur du scrotum a été réalisée et des images ont été prises avec et sans la manœuvre de Valsalva.

 

 

 
The testes are normal in size and echogenicity, and have a low-level uniform hyperechoic echogenicity without cystic, complex, or solid masses. Serpiginous anechoic tubular structures are identified (Scan1 and Scan 3). Some of these structures surrounded the entire right testicle. Similar but smaller tubular structures also surrounded the left testicle. The multiple anechoic structures have the appearance of dilated veins, termed varicoceles.
Color Doppler of both sides of the scrotum ( Scan 2, Scan 4) shows color flow with increased intra-abdominal pressure, and when the Valsalva maneuver is performed. This confirms the diagnosis of varicoceles.
 Les testicules sont normaux dans leur taille et leur échogènicité et ont un aspect hypoéchogène uniforme sans aucune masse solide ou kystique. Des structures tubulaires anéchogènes et serpigineuse sont identifiées (Cliché1 et Cliché 3). Ces structures entourent largement le testicule droit. Des structures tubulaires semblables mais plus petites sont également visible auteur du testicule gauche. Ces structures anéchogènes multiples ont l'aspect de veines dilatées, nommées : varicocèle.
Des images Doppler couleur des deux côtés du scrotum (Cliché2 , Cliché 4), avec une pression abdominale accrue et avec la manœuvre de Valsalva, ont été exécutée montrant un flux sanguins dans ces structures tubulaires. Ceci confirme le diagnostic de varicocèle.

 

 

 

 
Varicocele Varicocèle ________

 

Varicocele

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Definition :
Varicocele is a dilation (enlargement) of the internal spermatic veins that drain the testicle.

Pathophysiology :
Varicoceles are much more common (80-90%) in the left testicle than in the right because of several anatomic factors, including the angle at which the left testicular vein enters the left renal vein, the lack of effective antireflux valves at the juncture of the testicular vein and renal vein, and the increased renal vein pressure due to its compression between the superior mesenteric artery and the aorta (nutcracker effect). Numerous theories postulate how a varicocele can affect fertility: 1.Testicular temperature increases due to abnormal blood flow in the veins draining the testicle. 2.Abnormal concentrations of adrenal and renal substances may impede development of normal sperm. 3.Abnormal blood flow can also interfere with testosterone concentration, which in turn can interfere with sperm production.

Clinical:
Sometimes, these varicoceles cause no symptoms and are harmless. But sometimes they can cause pain or atrophy (shrinkage), or fertility problems. A varicocele may cause progressive damage to the testes, resulting in further atrophy and impairment of seminal parameters.

Ultrasonography :
Color-flow Doppler ultrasonography defines the anatomic and physiologic aspects of varicoceles by using real-time ultrasonography and pulsed Doppler in the same scan. The color of the signal identifies the blood flow and direction within the varicocele. The characteristic reverse flow of varicoceles is confirmed by prolonged flow augmentation within a colored flow area; the flow changes color (reverses) on real-time imaging A varicocele is a common entity described as an abnormal dilatation exceeding 2 mm in diameter of the veins of the pampiniform venous plexus associated with tortuosity. The normal diameter is up to 2.2 mm, which may increase to 2.7 mm during valsalva. The incidence of sub-clinical varicocele diagnosed by color Doppler ultrasound is even higher. The veins forming a varicocele are usually uniform in size measuring up to 5 mm in diameter. The vessel size increases if the patient is scanned when standing or whilst a valsalva manoeuvre is performed. Color flow Doppler ultrasound bas provided the highest level of confidence by demonstrating flow within a varicocele. Intratesticular varicocoele : Intratesticular varicocele is an extremely rare condition characterized by dilated Intratesticular veins and associated with ipsilateral varicocele. The mechanism of causation is the same as extratesticular varicocele. The dilated Intratesticular veins are seen as straight or serpentine hypoechoic tubular structures within the mediastinum testis radiating into the testicular parenchyma.

Differential :
Hydrocoele
Haematocoele
Lymphocoele
Pyocoele
Intrascrotal cyst and spermatocoele.
Testicular haematoma.
Testicular abscess.
Testicular cystic neoplasm.
Fluid-filled bowel loop (hernia).

Treatment :
No effective medical treatments for varicoceles have been identified. Surgical therapy: Reasons for surgical correction of a diagnosed varicocele include relieving significant testicular discomfort or pain not responsive to routine symptomatic treatment, reducing testicular atrophy, and addressing the possible contribution to unexplained male infertility.

Reference:
* 1: Akcar N, Turgut M, Adapinar B, Ozkan IR. Intratesticular arterial resistance and testicular volume in infertile men with subclinical varicocele. J Clin Ultrasound. 2004 Oct;32(8):389.
* 2: Gat Y, Bachar GN, Zukerman Z, Belenky A, Gorenish M. Physical examination may miss the diagnosis of bilateral varicocele: a comparative study of 4 diagnostic modalities. J Urol. 2004 Oct;172(4, Part 1 Of 2):1414-1417.
* 3 : Liguori G, Trombetta C, Garaffa G, Bucci S, Gattuccio I, Salame L, Belgrano E. Color Doppler ultrasound investigation of varicocele. World J Urol. 2004 Aug 18
* 4: Bavil'skii VF, Suvorov AV, Ivanov AV, Gubnitskii DA, Kandalov AM, Sagalov AV. [Choice of surgical method in the treatment of varicocele] Urologiia. 2003 Nov-Dec(6):40-3. Russian.
* 5: Diamond DA, Roth JA, Cilento BG, Barnewolt CE. Intratesticular varicocele in adolescents: a reversible anechoic lesion of the testis. J Urol. 2004 Jan;171(1):381-3.
* 6: Trussell JC, Haas GP, Wojtowycz A, Landas S, Blank W. High prevalence of bilateral varicoceles confirmed with ultrasonography. Int Urol Nephrol. 2003;35(1):115-8.
* 7: Kocakoc E, Serhatlioglu S, Kiris A, Bozgeyik Z, Ozdemir H, Bodakci MN. Color Doppler sonographic evaluation of inter-relations between diameter, reflux and flow volume of testicular veins in varicocele. Eur J Radiol. 2003 Sep;47(3):251-6.
* 8: Caskurlu T, Tasci AI, Resim S, Sahinkanat T, Ekerbicer H. Reliability of venous diameter in the diagnosis of subclinical varicocele. Urol Int. 2003;71(1):83-6.
* 9: Perel'man VM, Stepanov VN, Kadyrov ZA, Deniskova MV. [Ultrasound studies in varicocele] Vestn Rentgenol Radiol. 1999 Jan-Feb(1):35-40. Russian.
* 10 : Bolgarskii IS, Rakhmatullaev BM. [Color Doppler sonography of normal male genitalia and varicocele] Vestn Rentgenol Radiol. 2002 Mar-Apr(2):51-5. Russian.
* 11: Tasci AI, Resim S, Caskurlu T, Dincel C, Bayraktar Z, Gurbuz G. Color doppler ultrasonography and spectral analysis of venous flow in diagnosis of varicocele. Eur Urol. 2001 Mar;39(3):316-21.
* 12: Mihmanli I, Kurugoglu S, Cantasdemir M, Zulfikar Z, Halit Yilmaz M, Numan F. Color Doppler ultrasound in subclinical varicocele: an attempt to determine new criteria. Eur J Ultrasound. 2000 Sep;12(1):43-8.
* 13 : Resim S, Cek M, Fazlioglu A, Caskurlu T, Gurbuz G, Sevin G. Echo-colour doppler ultrasonography in the diagnosis of varicocele. Int Urol Nephrol. 1999;31(3):371-82.
* 14 : Kim ED, Leibman BB, Grinblat DM, Lipshultz LI: Varicocele repair improves semen parameters in azoospermic men with spermatogenic failure. J Urol 1999 Sep; 162(3 Pt 1): 737-40.
* 15 : Goldstein M, Gilbert BR, Dicker AP, et al: Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol 1992 Dec; 148(6): 1808-11.
* 16 : Kass EJ, Belman AB: Reversal of testicular growth failure by varicocele ligation. J Urol 1987 Mar; 137(3): 475-6.

 

 

 

 

 

 

 
 
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