Evaluation of the role of varicocelectomy including external spermatic vein ligation in patients with scrotal pain

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1 Blackwell Science, LtdOxford, UKIJUInternational Journal of Urology Blackwell Publishing Asia Pty LtdApril Original ArticleRole of varicocelectomy for paink Karademir et al. International Journal of Urology (2005) 12, Original Article Evaluation of the role of varicocelectomy including external spermatic vein ligation in patients with scrotal pain KENAN KARADEMIR, TEMUÇIN ŞENKUL, KADIR BAYKAL, FERHAT ATE Ş, CÜNEYD IŞERI AND DOĞAN ERDEN Department of Urology, Haydarpaşa Training Hospital, Gülhane Military Medical Academy, Üsküdar, Istanbul, Turkey Abstract Key words Objectives: The aim of the present study was to assess and compare pre- and postoperative scrotal pain in patients with varicocele who underwent varicocelectomy with different approaches. Methods: The study included 144 consecutive patients with left-sided varicocele who had left scrotal pain for more than 3 months. All patients underwent varicocele ligation using either a subinguinal or inguinal approach with or without external spermatic vein ligation. We asked the patients to complete an Assesment Questionnaire for Scrotal Pain both before and after the surgery. Results: The surgery was in 101 (83.4%) of the 121 patients available for follow up. Seventy-four (61.1%) patients reported the complete resolution of pain while 27 patients (22.3%) reported partial resolution. Symptoms worsened in a single case and pain persisted postoperatively in 19 cases (15.7%). There were no statistically significant differences in the characteristics of the pain and grade of varicocele between postoperative groups. A significant difference was observed in postoperative success between patients who had external spermatic vein ligation and those who did not, regardless of the surgical approach (inguinal or subinguinal). All patients who reported complete or partial resolution of pain stated that they would recommend surgery to relatives with the same problem. Conclusions : Varicocelectomy using either inguinal or subinguinal approaches is an effective and reasonable treatment option in this patient group and should include external spermatic vein ligation for a satisfactory outcome. external spermatic vein ligation, questionnaire, scrotal pain, varicocele. Introduction Many scrotal or extra-scrotal pathological conditions may cause chronic scrotal pain. Management of chronic scrotal pain is a problem that urologists face frequently in their daily practice. Chronic scrotal pain in particular is a significant management problem because of the paucity of effective treatment modalities. Additionally, the socioeconomic and psychological burden associated Correspondence: Kenan Karademir MD, GATA Haydarpaşa Eğitim Hastanesi, Üroloji Servisi, Üsküdar, Istanbul, Turkey. kkarademir@isbank.net.tr Received 5 January 2004; accepted 5 October with chronic scrotal pain and its management must not be overlooked. The overall incidence of varicocele is 10% to 15% in the general population of healthy males. 1 There is a clear association between varicocele, infertility and testicular growth arrest in adolescents and adult males. It is a cause of pain in 2% to 14% of men suffering chronic scrotal pain. 2,3 Chronic scrotal pain diminishes performance during daily activities to varying degrees in affected men. Many conservative therapeutic approaches may be offered to these patients, including limitation of physical activities, scrotal elevation and non-steroid antiinflammatory analgesics. Nevertheless, they often offer

2 Role of varicocelectomy for pain 485 no benefits in pain management. 4 Varicocelectomy is an alternative treatment for these patients. However, modern urology cannot know which patient with scrotal pain needs varicocelectomy and which method is the best in the treatment of men with painful varicocele. We designed the present prospective study to answer these cardinal questions regarding the management of chronic scrotal pain due to varicocele. We developed a self-administered questionnaire (see Appendix) to assess and compare pre- and postoperative scrotal pain in men who underwent varicocelectomy using either subinguinal or inguinal approaches, with or without external spermatic vein ligation. Materials and methods One hundred and forty-four consecutive male patients with a mean age of 21.1 years (range, 19 25) who presented with left scrotal pain due to left varicocele were included in the study between 1999 and All patients had daily tasks that required physical activities. Scrotal pain was described as heaviness or sensation in the scrotum or a dull or throbbing ache. The diagnosis of varicocele was made using selfdiagnosed symptoms, such as scrotal sensation or pain for more than a 3-month duration, along with the findings of both physical examination and color Doppler ultrasound. Patients who had other causes of scrotal pain, such as testicular torsion, epididymitis, inguinal hernia, testicular tumor or trauma, were excluded from the study. Varicocele was graded according to the criteria defined by Lyon and colleagues: Grade l as palpable only with Valsalva maneuver, Grade II as palpable without Valsalva and Grade III as visible from a distance. 5 We developed a self-administered questionnaire with seven items for the assessment of scrotal pain. This new instrument includes two domains: pain characteristics (duration, quality and intensity) and assessment of treatment outcomes (previous therapy, the absence/presence of pain in postvaricocelectomy period and a yes/no global assessment question regarding patient satisfaction, that is overall, would you recommend this operation to your relative with the same problem? ) All patients underwent left varicocele ligation using either a subinguinal or inguinal approach under local anesthesia. Only those patients who underwent ligation for pain were included in the present study. All patients were asked to return for a follow-up visit 3 months after surgery. Follow up evaluation included a physical examination and administration of the second domain of The Assessment Questionnaire of Scrotal Pain. Statistical analysis SPSS (version 7.5 Windows; SPSS, Chicago, IL) software program was used for statistical analysis. The comparison of patients for preoperative state and postoperative outcome was performed using c 2 test. P = 0.05 was considered statistically significant. Results Of 144 patients, 121 (84%) were available for followup, with a mean period of 4.3 months (range, 3 11 months) after varicocele ligation. The average duration of pain before presentation was 17.3 months (range, 3 months to 5 years). Table 1 shows patient characteristics and comparison of treatment outcomes in terms of varicocele grade, quality and intensity of pain and operation techniques. There were neither intraoperative nor postoperative complications. Of 121 patients, 74 (61.1%) reported the complete resolution of pain, 27 patients (22.3%) stated their pain became less (partial resolution). Thus, varicocele ligation was in 101 (83.4%) patients. Symptoms got worse in one case, while in 19 cases (15.6%), pain persisted postoperatively. Scrotal color Doppler ultrasound demonstrated significant retrograde blood flow (reflux) in two cases of the 12 patients in the failure group. There were no statistically significant differences either in the quality and intensity of pain or varicocele grade between postoperative outcome groups (P > 0.05; Table 1). Additionally, there was also no statistical difference between varicocele grade and pain intensity (VAS, Visual Analog Scale; P > 0.05). Of 121 patients, 56 had undergone one or more (two different treatment attempts in seven cases) medical therapies previously; however, these provided no benefits in the management of pain in any patient. Detailed postoperative outcomes in patients who underwent medical therapy previously are shown in Table 2. We found no significant difference in postoperative treatment outcomes between patients who previously underwent a trial of conservative management and those who did not (P > 0.05). We observed abnormal dilatation of the external spermatic vein in 79 of 121 cases during surgery and ligated all dilated veins using either inguinal or subinguinal approaches. Of those 79 patients, 73 (92.4%) reported complete resolution of pain, five (6.3%) had a partial resolution of pain and complained of occasional dull or throbbing ache in the scrotum similar to the pain before surgery. Only in one case (1.3%) did symptoms persisted postoperatively. The difference in postopera-

3 486 K Karademir et al. Table 1 Patient characteristics and comparison of treatment outcomes in terms of varicocele grade, quality and intensity of pain and operation techniques Asssesment criteria Preoperative period Completely Postoperative outcome Partially Unsuccesful P-value Variococele Grade >0.05 I II III Pain quality >0.05 Dull Sharp Minimal Pulling sensation Pain intensity (Visual analog scale) > Operative technique Sub-inguinal Inguinal Table 2 Postoperative outcomes of patients who underwent medical therapy previously Medical therapy option Preoperative Postoperative outcome Completely Partially Un Scrotal elevation Antipsycotics Non-steroidal anti-inflammatory drug Venotonic/protectors tive success between patients who underwent external spermatic vein ligation and those who did not was statistically significant (P = ). We could not detect any external spermatic vein in 42 of 121 cases and only one of these 42 patients reported a complete resolution of pain. Of the 121 patients who were available for followup 3 months postoperatively, 115 (95%) stated that they would recommend surgery to their relatives with the same problem. While all patients who reported complete or partial resolution after surgery marked yes in the seventh question of The Assessment Questionnaire of Scrotal Pain, 14 of the patients whose symptoms persisted answered the question in the same manner. Discussion The most common complaint in patients with varicocele is a dull and throbbing scrotal pain that worsens with straining and exercise. Many urologists see varicocele patients who present primarily with scrotal pain only occasionally and cannot form an objective opinion based on their own experience. Urologists who take care of patients whose jobs require working mostly in standing position or heavy physical efforts, like military or police personnel, often encounter patients with painful varicocele. The treatment often used for chronic scrotal pain so far consists of conservative measures, such as scrotal elevation, anti-inflammatory medications and limita-

4 Role of varicocelectomy for pain 487 tions in activity, often leading to unacceptable lifestyle restrictions. 6 Varicocele ligation for the treatment of pain is controversial, with a paucity of literature supporting its use and is only recommended in a highly selected population of men who have specific pain complaints and in whom conservative management has failed. Also, there is no prospective, randomized study that compares conservative management to surgical correction for painful varicocele in the published literature. Furthermore, the variety of approaches used for varicocelectomy treatment is due to the lack of a gold standard. Biggers and Soderdahl reported a success rate of 48% in their retrospective study including 50 patients undergoing ligation of the left internal spermatic vein for painful varicocele. 7 Peterson et al. performed a retrospective review of 35 patients undergoing different ligation techniques (the inguinal or subinguinal approach in 24, high ligation in 10 and laparoscopic repair in one) for painful varicocele. The complete resolution rate in their study was reported as 86%. 8 Yaman et al. performed 82 varicocele ligations using a microsurgical technique. In their study, 72 patients (88%) who underwent surgery for painful varicocele reported resolution of pain. 9 Response criteria were not based on subjective patient or healthcare comments in these studies. We standardized the study population for pain characteristics and response options. Therefore, our assessment questionnaire is the first method in the evaluation of chronic scrotal pain due to varicocele and its treatment outcome. Our total success rate based on the questionnaire is 83.4%, including complete (61.1%) and partial (22.3%) pain resolution. Table 3 shows the comparisons of studies on surgical treatment of painful varicocele. Based on our experience and data from studies comparing different ligation techniques in patients with pain and infertility, we believe that postoperative outcome is closely associated with the technique used. Biggers and Soderdahl used the high ligation technique with a success rate of 48%, while Peterson et al. mainly used the transinguinal approach with a complete resolution rate of 86% and Yaman et al. reported a success rate of 88% using microsurgical ligation. 7 9 We also used the transinguinal approach and obtained a success rate similar to those who used the same technique. External spermatic veins can be ligated using either inguinal or subinguinal approaches and our data suggest that the postoperative success rate is related to the ligation of the external spermatic vein which is not possible to perform using high ligation. This fact may also have contributed to the high failure rate reported with high ligation. However, studies on varicocelectomy which used transinguinal approaches did not indicate whether the external spermatic veins (the cremasteric veins) were ligated or not. Also, cremasteric muscle ischemia may play a significant role as the cause of pain in men who stay mostly in upright position in their daily practice, since their symptoms worsen with straining and exercise. However, no data in the published literature supports this theoretical consideration. Biggers and Soderdahl stated that an attempt of prior management may account for high success rate in postvaricocelectomy period. 7 However, we did not obtain an association between postoperative success rate and a previous trial of conservative measures. Yaman et al. examined recurrence using color Doppler ultrasound in the failure group and they found reflux recurrence in two of the nine patients. They also indicated that the failure rate was associated with the preoperative varicocele grade. 9 We could not confirm this in the present study, even though the number of patients with chronic scrotal pain increased with the increasing grade of varicocele. However, the presence or absence of scrotal pain does not correlate well with varicocele grade. On the other hand, it is thought that postoperative success rate is associated with pain characteristics. We could not find such an association in the present study. Table 3 Comparison of the studies on surgical treatment of painful varicocele Number of patients Mean age (years) Duration of pain (months) Previous medical therapy Operation technique Time of Postoperative Assessment (months) Success rate (%) Briggers (1981) HL 48 Peterson (1998) Yaman (2000) SI / HL / LL Microsurgery / SI Karademir (2003) SI / IL HL, high ligation; IL, inguinal ligation; LL, laparoscopic ligation; SI, subinguinal ligation.

5 488 K Karademir et al. In conclusion, we believe that conservative approaches result in low success rates and are effective only during the treatment period in patients with chronic scrotal pain due to varicocele and that varicocelectomy using either inguinal or subinguinal approaches is an effective and reasonable treatment option in this patient group and should include external spermatic vein ligation. References 1 Greenberg SH. Varicocele and male fertility. Fertil. Steril. 1977; 28: Kass EJ, Bogdan M. Result of varicocele surgery in adolescents. a comparison of techniques. J. Urol. 1992; 148: Marmar JL, Kim Y. Sublingual microsurgical varicocelectomy: a technical critique and statistical analysis of semen and pregnancy data. J. Urol. 1994; 52: Lissos I, Spiro FI. Non-operative treatment of varicocele. S. Afr. Med. J. 1986; 70: Lyon RP, Marshall S, Scott MP. Varicocele in childhood and adelescence: implication in adulthood infertility. Urology 1982; 19: Ribe N, Manasia P, Sarquella J, Grimaldi S, Pomerol JM. Clinical follow-up after subingunial varicocele ligation to treat pain. Arch. Ital. Urol. Androl. 2002; 74: Biggers RD, Soderdahl DW. The painful varicocele. Mil. Med. 1981; 146: Peterson AC, Lance RS, Ruiz HE. Outcome of varicocele ligation done for pain. J. Urol. 1998; 159: Yaman O, Özdiler E, Anafarta K, Gögü ş O. Effect of microsurgical sub-inguinal varicocele ligation to treat pain. Urology 2000; 55: Appendix Individual items of The Assesment Questionnaire of Scrotal Pain and response options Question 1: How long have you been suffering from scrotal pain? a. Less than 3 months b. 1 years c. 5 years d. More than 5 years Question 2: How do you define your pain? a. A dull ache b. A sharp ache c. Minimal d. Pulling sensation Question 3: How do you describe the inconvenience of your pain? a. It does not diminish my daily activities b. It diminishes my daily activities c. I take analgesics for the pain d. No benefit from analgesics Question 4: How do you mark the intensity of your pain on the visual analog scale? Question 5: Which treatment have you previously undergone for this complaint? a. Analgesics b. Antipsycotics c. Venotonic/venoprotector drugs d. Scrotal elevation Question 6: How do you feel yourself after surgery? (3 months after operation) a. My pain has completely resolved b. My pain lessened c. My pain persists d. My pain worsened Question 7: Overall, would you recommend this operation to a relative with the same problem? a. Yes b. No