in the name of god hassan jamshidian md imam khomeini hospital
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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
-----------------------------------------------------------
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
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