VARICOCELE

Varicocele is a clump of enlarged and engorged veins that develops in the spermatic cord within the scrotal sac. The spermatic cord is made up of veins, arteries, lymphatic vessels, nerves, and vas deferens.

If the valves that regulate bloodflow from these veins are defective (usually from birth), blood does not drain from the testicles efficiently, causing swelling in the veins above and behind the testicles.The pooling of blood in the engorged vessels results in warming of the testis.


A varicocele can develop in one or both testicles, but in about 85% of cases, the left testicle is involved.
A varicocele is found in approximately 15% of  men.  In men evaluated for infertility , varicoceles are found in approximately 40% of patients.

Varicocele affects semen quality because of increased heat to the testicle. The dilated veins allow warm blood from the abdominal cavity to flow around the testicle. This causes overheating of the testicle which then impairs its function. Commonly, a low sperm count, poor movement, and abnormally shaped sperm are found in men with varicoceles. A varicocele surrounding 1 testicle may affect the testicle on the opposite side of the body. A varicocele may also lead to impaired growth of the testicle and thus the testicle on the side of a varicocele may be smaller than the other..

Signs and symptoms

Most men with varicocoeles have no symptoms and they are diagnosed on routine physical examination or during infertility work up.

Signs and symptoms include the following:

• Pain in the testicle
• Feeling of heaviness or discomfort in the testicle(s) 
• Infertility
  
• Shrinkage of the testicle(s)
• Visible enlarged vein or vein that is able to be felt

 Large varicoceles are easily identified on physical examination; they have the classic "bag of worms" appearance surrounding the testis.

Grading of varicocoeles:

• Grade 1-  varicocele that is palpable only during straining (Valsalva maneuver).
• Grade 2 - varicocele in which the lesion is palpable without a Valsalva maneuver.
• Grade 3 - varicocele that is visually detectable

Diagnostics:

Ultrasound is the examination of choice for investigating varicoceles, and it remains the most practical and most accurate noninvasive technique.

Treatment

If the varicocele causes pain or decreased size of the testis (rare) or if the condition is causing infertility (most common), surgery is recommended.

Urologists correct varicoceles by performing a surgical procedure called varicocelectomy.


The Male Infertility Best Practice Policy Committee of the American Urological Association recommends that varicocele treatment should be offered to the male partner of a couple attempting to conceive when all of the following are present

• A varicocele can be felt..
• The couple has documented infertility.
• The female has normal fertility or potentially correctable infertility.
• The male partner has one or more abnormal semen parameters or sperm function test results.

In addition, adult men whose varicocele can be felt and semen analyses show abnormal findings but are not currently attempting to conceive should also be offered varicocele repair.

A varicocele is the most correctable factor in a male with poor semen quality; therefore, varicocele repair should be considered a viable option for individuals and couples with otherwise unexplained infertility because varicocele repair has been shown to improve semen parameters in most men and possibly improve fertility.

VESICOURETERAL REFLUX

What is vesicoureteral reflux? (VUR)

The normal urination process involves bladder contraction and urine flow out of the body through the urethra.

With vesicoureteral reflux (VUR), some urine goes back up into the ureters and possibly up to the kidneys. This process exposes the kidneys to infection.

In children, especially those in the first 6 years of life, urinary infection can cause kidney damage. The injury caused by infection to the kidney may result in scars in the kidney and loss of future growth potential or widespread scarring and loss of the normal kidney tissues. Even a small area of scarring in one kidney may be a cause of high blood pressure later in life. Untreated, severe reflux on both sides can result in kidney failure requiring dialysis or kidney transplantation.

VUR is most commonly diagnosed in infancy and childhood after the patient has a urinary tract infection (UTI). About one-third of children with a UTI are found to have VUR.

VUR can lead to infection because urine that remains in the  urinary tract provides a place for bacteria to grow. But sometimes the infection itself is the cause of VUR.

There are undetermined genetic risk factors which may affect the development of VUR. About 34% of patients who have the condition have siblings who are also affected.

Types of VUR:

Primary reflux

The most common cause for primary reflux in children is an abnormality in the section of the ureter that enters the bladder ( intravesical ureter). The intravesical ureter may not be long enough to enable the ureter to sufficiently act as a valve to prevent urine reflux, or the ureter may be inserted abnormally into the bladder.

Other causes of primary reflux include abnormalities in muscle of the bladder, abnormalities in the location of the urethral opening and abnormalities in the shape of the urethral opening. 

Secondary reflux

Secondary reflux is often caused by urinary tract infection which causes inflammation and swelling of the ureter. UTI may cause vesicoureteral reflux or vesicoureteral reflux may promote the growth of bacteria in the urinary tract, causing UTI.

Secondary reflux may also be caused by urinary tract abnormalities like narrowing of the ureter; duplicated ureters; ureterocele) and obstructions from stones or tumors. 



Evaluation

An ultrasound of the kidneys and bladder is done to 1) evaluate hydroneprosis and kidney growth and 2) detect abnormalities that cause reflux.

A renal scan is done to evaluate kidney growth and detect presence of scarring.

A voiding cystourethrogram (VCUG) is performed to determine if an abnormality in the urinary tract is causing reflux. A contrast dye is instilled into the bladder through a catheter and a series of x-rays are taken.

Grading of VUR

Grade I (least severe) to Grade V (most severe):

• Grade I results in urine reflux into the ureter only.
• Grade II results in urine reflux into the ureter and the renal pelvis, without swelling of the top of the ureter (hydronephrosis).
• Grade III results in reflux into the ureter and the renal pelvis, causing mild hydronephrosis.
• Grade IV results in moderate hydronephrosis.
• Grade V results in severe hydronephrosis and twisting of the ureter

Mild-to-moderate degrees of reflux (grades I to III) have a good chance of spontaneous resolution with age in over 80% of children. This typically occurs over the span of few years. Unfortunately, we do not know exactly when the reflux will go away for a particular child.
The chance of spontaneous resolution of high grade reflux (IV to V) is much lower.

Treatment

1) Antibiotic prophylaxis for VUR Gr II-III
2) Endoscopic treatment for VUR Gr I-IV
3) Open surgery  for VUR Gr IV-V


Follow-Up
All patients with a history of reflux will have life long monitoring. Even if the reflux resolves, there is still risk of developing kidney insufficiency, hypertension, and pregnancy-related problems.This usually involves periodic visits to the pediatrician and have the following taken: height and weight, blood pressure, and urine analysis. Kidney function can be evaluated by blood tests (creatinine and BUN) or by creatinine clearance or glomerular filtration rate. Occasional ultrasound tests will ensure that kidney growth is on target for age. Female patients should be carefully monitored during their pregnancy.