varicocele presentasi.ppt

8/13/2019 Varicocele presentasi.ppt

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Varicocele


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Background

Varicocele

dilatation of the pampiniform venousplexus

Occurs approximately 15-20% of all males and in 21-

41% of infertile males

(Medscape from webMD)

Valvularincompetence

Disruption ofinternal

spermaticveins bloodflow return

Dilatation ofpampiniform

venous plexusVARICOCELE


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Etiology

80-90% in the left side because of several anatomicfactors:

Left testicularis vein is longer than the right

The angle at which the left testicularis vein enters the left

renal vein The lack of effective anti reflux valves at the juncture of

the testicular vein and renal vein

The increased renal vein pressure due to its compression

between the superior mesenteric artery and the aorta



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Etiology

If there is a right side varicocele / bilateralvaricocelesshould suspected:

Retroperitoneal space abnormalites (vein obstruction due

to tumor or thrombus)

Congenital anomaly: Right testicularis vein enters theright renal vein


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Predisposition Factors

Increases abdominal pressure Trauma Injury

Failure of organs:

Heart

Liver

Renal


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Pathophysiology

Varicoceles can disrupt the spermatogenesisprocess in several ways:

Blood flow stagnation in testicular sirculationO2supply to the testiclestesticles hypoxia

Renals and adrenals metabolite (catecolamin andprostaglandin) reflux through the internal spermatic vein

to the testicles

intratesticular temperature

The presence of anastomosis between the left and right

pampiniform venous plexusenabled the metabolite

material streamed from the left testicles to right testicles

impaired right testicular spermatogenesis


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Presentation

Usually asymptomatic, Often seeks an evaluation for infertility or feel pain

and heavy


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Scrotal Examination

Performed in a standing position

inspection andpalpation of the scrotal

If neededpatients were asked to strain (valsava

manouver)

An obvious varicoceleoften described as feelinglike a bag of worms


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Scrotal Examination

Clinically varicoceles can be classified into thefollowing 3 groups:

Grade Ipalpable only with valsava maneuver which

increases intraabdominal pressure, thus impeding

drainage and increasing varicole size

Grade IIpalpable without need of valsava maneuver

Grade IIIeasily identified by inspection alone


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Scrotal Examination

Testicles

compared both the testis Sizewidth, length, and the volume (using

orchidometer)

Consistency

In some conditions the testicles are soft and smallindicates the damage of the germinal cell


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Imaging Studies

Using an ultrasound with color Doppler Indication: for clinically unpalpable varicocele but

therere another signs that indicates varicocele

(subclinical varicocele)

Can detect blood flow in pampiniform plexus


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Semen Analysis

To measure how far the varicocele caused thedamage to the seminiferous tubule

McLeodsemen analysis result shows the stress

pattern:

sperm motility the amount of immature sperm

Morphology abnormalities


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Surgical Therapy

Indications:

Palpable varicocele

Symptomatic varicocele

Bilateral varicocele

Ipsilateral testicular atrophy

Abnormal semen parameters

Contraindications:

Injury of scrotum

Hydrocele Coagulation disorder

Failure of organs:

Renal - Heart

Liver


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Surgical Therapy

The 3 most common surgical approaches: Inguinal approache

Retroperitoneal approache

Subinguinal approache

All abnormal veins are tied permanently to prevent

continued abnormal blood flow


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Surgical Therapy

Goal: Relieving significant testicular discomfort/pain not

responsive to routine symptomatic treatment

Reducing testicular atrophy (vol < 20ml, length < 4cm)

Preservation of arterial flow to the testis


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Postoperative

Rest for 2 days

Outer dressings are removed 48 hours after surgery.Small strips of tape are left in place for 7-10 days

Permitted bathing/showering for 48hours aftersurgery

Dietstarts with fluids and gradually return to solidfood

Prescribe pain medication

Patients can engage in normal, nonstraining activitywhen they feel up to it If activity causes discomfortshould be discontinued

Patients can resume more strenuous activities (eg,weightlifting, jogging) after 2 weeks

Refrain from intercourse for 1 week


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Evaluation

The increased of testicular volume Improvement of semen analysiss result (every 3

month)

May take up to 3-4 months

66-70% patients have improved bulk semen parameters Conception

40-60% patients have increased conception rates



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Complications

Hydrocele in 2-5% patients

Recurrent rates of varicocele as high as 10%

Injury to the testicular artery in 0.9% of

microsurgical varicocele repair



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References

Diunduh dari :http://emedicine.medscape.com/article/438591-

overview

http://www.maleinfertility.org/new-varicocele.html

Dasar2 urologi edisi 3 Basuki Blueprints urology Ch.4 Male Infertility
http://emedicine.medscape.com/article/438591-overviewhttp://emedicine.medscape.com/article/438591-overviewhttp://www.maleinfertility.org/new-varicocele.htmlhttp://www.maleinfertility.org/new-varicocele.htmlhttp://www.maleinfertility.org/new-varicocele.htmlhttp://www.maleinfertility.org/new-varicocele.htmlhttp://emedicine.medscape.com/article/438591-overviewhttp://emedicine.medscape.com/article/438591-overviewhttp://emedicine.medscape.com/article/438591-overview

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