Varicocele presentasi.ppt
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Transcript of 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
(Medscape from webMD)
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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
(Medscape from webMD)
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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
(Medscape from webMD)
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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