decreased when the man lies down. The varicocele cannot usually be palpated lying down.

Transcription

1 Variccele - Management View full scenari Hw d I knw my patient has a variccele? The man may present with cncern abut scrtal swelling r scrtal pain, r a variccele may be an incidental finding n physical r ultrasngraphic examinatin. A variccele is usually asymptmatic, but 2 10% f affected men may have vague dragging r heavy sensatins and aching pain in the scrtum r grin. A variccele presents characteristically as a 'bag f wrms' within the spermatic crd abve the testis n the left side f the scrtum: The scrtum n the side f the variccele may be seen t hang lwer than n the nrmal side. Dilatin and trtusity f the veins is increased n standing and is usually decreased when the man lies dwn. The variccele cannt usually be palpated lying dwn. Perfrming the Valsalva maneuvre whilst standing increases dilatin. There may be a cugh impulse. If there is uncertainty abut the diagnsis, see the CKS tpic n Scrtal swellings. Basis fr recmmendatin The basis fr these recmmendatins is expert pinin in textbks [Schwartz, 1999; Russell et al, 2004; Sandlw, 2004; Sweetland and Cnway, 2004; Brwse et al, 2005; Dasgupta and Tiptaft, 2005], review articles [Junnila and Lassen, 1998; Kass, 2001], and guidelines n male infertility frm the Eurpean Assciatin f Urlgy [Dhle et al,

2 Variccele - Management View full scenari Wh shuld I refer? Refer urgently t a urlgist t exclude a tumur: If a variccele appears suddenly, especially if the man is lder than 40 years f age and the variccele remains tense when lying dwn. If there is a slitary right-sided variccele. Refer t a urlgist if there is uncertainty abut the nature f a scrtal swelling. Refer rutinely t a urlgist fr cnsideratin f variccele ablatin: If it is causing distress r embarrassment. If there is pain r discmfrt. Refer adlescents with a variccele t a urlgist: If there are cncerns abut reduced ipsilateral testicular vlume. If the by r parents/guardians are cncerned by appearance r symptms and cannt be fully reassured in primary care. D nt rutinely refer men with a left-sided variccele fr ultrasngraphy t lk fr an underlying tumur. If a variccele is fund in the male partner f an infertile cuple, see the CKS tpic n Infertility fr mre infrmatin n assessment and when t refer. The Natinal Institute fr Health and Clinical Excellence recmmends that men shuld nt be ffered surgery fr varicceles as a frm f fertility treatment because it des nt imprve pregnancy rates. Basis fr recmmendatin 2

3 Mst varicceles are idipathic withut underlying malignancy. Available evidence des nt supprt referral fr ultrasngraphy t exclude a renal tumur in men presenting with a scrtal variccele. Rare serius underlying causes include impairment f venus drainage due t venus thrmbsis, tumur invasin, r extrinsic cmpressin by an intra-abdminal tumur. A variccele (whether acute, symptmatic, r an incidental finding) will rarely be the sle feature f a renal r retrperitneal tumur: If an lder man (> 40 years f age) presents with a newly symptmatic variccele, especially ne that des nt empty n lying dwn, an advanced renal tumur is pssible, althugh ther clinical signs and symptms pinting t the underlying cause are likely t be present [Cuschieri et al, 1996; Junnila and Lassen, 1998; Russell et al, 2004; Dasgupta and Tiptaft, 2005; El- Saeity and Sidhu, 2006]. When a variccele develps nly n the right side, vena caval bstructin frm a renal carcinma r ther retrperitneal tumur shuld be excluded [Junnila and Lassen, 1998; Dasgupta and Tiptaft, 2005]. Althugh experts suggest referral fr cnsideratin f ablatin if the man has pain r discmfrt [Junnila and Lassen, 1998], there is n gd evidence t guide management. BMJ Clinical Evidence fund n cmparative studies f sufficient quality t guide the chice amng expectant management, surgery, emblizatin, r sclertherapy t relieve pain and discmfrt caused by a variccele [Shekhar Biyani et al, 2007]. Hwever, fr men with bthersme symptms, discussin f likely benefits and pssible risks f alternative management ptins is warranted. Mst urlgists accept discmfrt as a valid indicatin fr treatment [Dhle et al, 2007]. It is reasnable t cunsel all adlescents with a variccele, and their families, that the effects n future fertility are impssible t predict with abslute certainty but that the risk f infertility is prbably small [Kass, 2002]. Mst CKS expert reviewers believe that it is currently apprpriate t manage mst adlescents with a variccele by bservatin and mnitring f testicular size (either by the adlescent r the clinician). Variccele ablatin shuld be cnsidered fr thse with abnrmal testicular vlume [Diamnd, 2007], as imprvements in sperm parameters and testicular vlume have been demnstrated after variccelectmy [Okuyama et al, 1988; Laven et al, 1992]. Available evidence in a Cchrane review suggests that men shuld nt be ffered surgery fr variccele as a frm f fertility treatment because it des nt imprve pregnancy rates. The Natinal 3

4 Institute fr Health and Clinical Excellence have based their recmmendatin n this review, but cmmented that until a full reprt f the Wrld Health Organizatin multicentre trial is published n the effect f variccele repair n pregnancy rates, the effectiveness f variccele repair in men with abnrmal semen remains uncertain [Natinal Cllabrating Centre fr Wmen's and Children's Health, 2004]. What advice shuld I give t smene wh has a variccele? Reassure that, in mst men, the variccele des nt require any treatment and is nt likely t cause any symptms r lng-term cmplicatins. Initially, manage assciated discmfrt by recmmending supprtive underwear and simple analgesia. If relevant, explain that althugh varicceles may be assciated with fertility prblems, nearly tw-thirds f men wh have a variccele have n difficulty in fathering children. Fr men with fertility prblems, explain that available evidence des nt supprt the use f variccele ablatin t imprve pregnancy rates. If variccele ablatin is being cnsidered, explain that the urlgist will fully discuss the risks and benefits f bth surgical and percutaneus emblizatin prcedures and that cmplicatins are infrequent and mild. Optins fr variccele ablatin include: Surgery either by retrperitneal, inguinal, subinguinal, r laparscpic appraches. vein. Percutaneus radigraphic retrgrade emblizatin via the femral Percutaneus antegrade emblizatin via the scrtum. Basis fr recmmendatin N evidence supprts the wearing f clse-fitting underwear, and the recmmendatin is based n expert advice in textbks [Russell et al, 2004; Ellis et al, 2006]. Althugh varicceles are present in many men wh father children [Sandlw, 2004], evidence indicates that they are als assciated with reduced fertility [Jhnsn et al, 1970; Evers and Cllins, 4

5 2003]. Hwever, at present, the available evidence des nt supprt the use f variccele ablatin t imprve pregnancy rates. A reprt frm the Practice Cmmittee f the American Sciety fr Reprductive Medicine states that nly larger varicceles which are typically easily palpable have been clearly assciated with infertility [American Sciety fr Reprductive Medicine, 2006]. Variccele surgery carries a small risk f wund infectin, hydrcele, persistence r recurrence f the variccele and, rarely, testicular atrphy. There may be scrtal numbness and persistent pain. Intraperitneal cmplicatins (e.g. injury t the bwel, bladder, r majr bld vessels) are uncmmn. Surgery successfully eliminates mre than 90% f varicceles [American Sciety fr Reprductive Medicine, 2006]. Percutaneus emblizatin may be assciated with less pain, but results are variable and the spermatic vein cannt be accessed in sme men [American Sciety fr Reprductive Medicine, 2006]. 5