In the name of God

Hassan Jamshidian MD

Imam Khomeini Hospital

Varicocele• Is found in:• 15% of the general population

• 35% of men with primary infertility

• 70-81% of men with the secondary infertility

Definition

Abn. Tortuosity and dilatation of the testicular veins within

the spermatic cord

varicocele

• The most correctable cause of male infertility

• Approximately 90% left sided

• 10% bilateral,some reports more

Why is predominant in Lt. side?

• 1-Difference in the venous drainage

• 2-Absence of the venous valves is more common on the Lt side

• 3- The left renal vein may be compressed between the superior mesenteric artery and the aorta

Varicocele & Infertility• 1-Temperature• 2-Reflux of the renal and adrenal

metabolites from the renal vein & hypoxia

• Decreased motility in 90% & count in 20%

• Stress pattern

Varicocele-Grading

• Grade 1

• Grade 2

• Grade 3

• Grade sub clinical

varicocele• Majoity of men with varicocele are

fertile• Normal gonadotropin and testosterone

level• Some elevated FSH• Abn. GnRH are often present in

adolescent and subfertile men with varicocele

Whom should be repaired?

• 1-in infertility with any grade• 2-Adolescents with grade 2 or 3 with

ipsilateral testicular growth retardation

• The presence of a varicocele alone is not an indication for varicocele repair,because the majority of men with varicocele are fertile

Repair of varicocele will halt any further damage to

testicular functionIn large percentage of men ,results in improved spermatogenesis(70%),

as well as enhanced Leydig cell function

Conception rate 40-50%

Techniques of Varicocelectomy

Technique artery p. Hydc. Failure

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Retropr. No 7% 15-20%

Inguinal No 3-30% 5-15%

Laparoscopic Yes 12% 5-15%

Microcopical Yes 0 1%

Hydrocele

Hydrocele-Definition

• The accumulation of fluid within the tunica vaginalis

Hydrocele

•1-Communicating

•2-Simple

Communicating hydrocele

• -Persistence of the processus vaginalis• Smaller in the morning• Frequently bluish hue in thin scrotal skin• Easy transillumination• Same anatomic defect in hernia• Congenital in origin• All should be explored through an inguinal

incision

Simple hydrocele

• Caused by:

• 1-After varicocelectomy

• 2-Radiation

• 3-Testicular tumors

• 4-Orchio-epididymites

• 5-Trauma

• 6-Idiopathic(The most common)

Ultasonography is the best method for diagnosis of the

hydrocele

DD of Hydrocele• Cord cyst

• Spermatocele

• Tumor of the testis

• Hernia

Hydrocelectomy

• 1-Excisional Technique

• 2-Plication Technique

• 3- Window operation

• 4-Dartos Pouch Technique• 5-Scleroplasty(Tetracycline derivatives)

Comlications of hydrocelectomy

• Hematoma (the most common)

• Injury to the epididymis or the vas deferens

Undescended Testis

UDT classification

• Cryptorchid

• Ectopic

Cryptorchid

• Intra-abdominal(retroperitoneal)

• Intracanalicular

• Extracanalicular(suprapubic or infrapubic)the most common

Ectopic testis

• Misdiracted outside the normal path of descent

• Superficial inguinal (the most common)

• Transverse scrotal

• Femoral

• Perineal

• Prepenile

UDT incidence• 3% of full term at birth• Unilateral is more common than bilateral• 30% in premature infants• Prevalent among small for age, low birth

weight, twin neonates• 70-77% descend spontaneously by 3 months

of age• By age 1 year ,incidence is 1% ,and remains

constant throughout adulthood

In order for normal spermatogenesis to occur ,it is necessary for the normal testes to descend into the scrotum, a

specialized, low temp. environment that maintains a

temp. 2 to 3 F lower than core body temp.

Theories of Descent and Maldescent

• Endocrine factors

• Gubernaculum

• Intra-abdominal pressure

Consequences of UDT

• 1-Infertility

• 2-Neoplasia

• 3-Hernia

• 4-Testicular torsion

UDT-neoplasia

• Incidence of test. Tumor in general population is 1 in 100,000,but in UDT is 1 in 2,550(40 times more)

• Orchiopexy does not reduce the cancer rate ,but can help in early diagnosis

• The most common type in UDT is Seminoma• The prevalence of carcinoma in situ is 1.7%

in UDT

Diagnosis-UDT

• Laparoscopy

• CT

• MRIUltrasonography

• Testicular angiography or venography

management-UDT

• Orchiopexy before or at 1 year of age

• Hormonal therapy(HCG, GnRH)

UDT-surgical treatment

Torsion of the spermatic cord and

testis

Torsion

• Intravaginal

• Extravaginal

• Gold standard time 6 hours