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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 35  |  Issue : 2  |  Page : 65-68

The evaluation of saphenofemoral insufficiency in primary adult varicocele


Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Submission08-Sep-2015
Date of Acceptance26-Nov-2015
Date of Web Publication10-Mar-2016

Correspondence Address:
Mohamed A Sallam
MD, PhD, Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Abasseya, 11591 Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-6530.178463

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  Abstract 

Purpose
The aim of this study was to evaluate the possible relationship between varicocele and saphenofemoral insufficiency in patients diagnosed with primary varicocele.
Patients and methods
A total of 40 patients with the primary diagnosis of varicocele were included in the study. A total of 40 age-matched healthy adults were also included in the study as a control group. Varicocele was diagnosed by means of palpation and observation of each spermatic cord in standing position before and during a Valsalva maneuver. In addition, scrotal Doppler and lower extremity venous Doppler ultrasonography (US) were performed. Patients who had spermatic varicose vein larger than 3.0 mm were included in the study group as a varicocele patient. At the lower extremity venous Doppler US, a retrograde flow lasting longer than 0.5 s during normal breathing or at the Valsalva maneuver was considered to be indicative of saphenofemoral junction (SFJ) insufficiency.
Results
Twenty-five (62.5%) patients had SFJ insufficiency in the study group, whereas 11 patients (27.5%) had insufficiency in the control group. Of the 40 study participants, 10 participants had recurrent varicocele. All of them were seen to have SFJ reflux on Doppler US (100%) (P = 0.014). The patients with primary varicocele had a statistically significantly (P = 0.02) higher rate of venous insufficiency in their SFJs when compared with the control group.
Conclusion
The results of the present study show that the incidence of SFJ reflux increases in individuals with varicocele, with a higher incidence in cases of recurrent varicocele. Depending on the common presence of valvular insufficiency, we believe that the presence of varicocele should be investigated in the young population suffering from SFJ insufficiency.

Keywords: Infertility, saphenofemoral insufficiency, varicocele


How to cite this article:
Sallam MA, Khalil M, Abdallah MA. The evaluation of saphenofemoral insufficiency in primary adult varicocele. Egypt J Dermatol Venerol 2015;35:65-8

How to cite this URL:
Sallam MA, Khalil M, Abdallah MA. The evaluation of saphenofemoral insufficiency in primary adult varicocele. Egypt J Dermatol Venerol [serial online] 2015 [cited 2020 May 28];35:65-8. Available from: http://www.ejdv.eg.net/text.asp?2015/35/2/65/178463


  Introduction Top


Varicocele, the most common surgically correctable cause of male infertility, is characterized by abnormal tortuosity and dilation of the pampiniform plexus within the spermatic cord. Although the exact etiology of varicocele is not known, the pathogenesis may be associated with various factors resulting in increased retrograde blood flow, or increased pressure in the pampiniform plexus and the internal spermatic vein [1],[2].

Possible mechanisms are the absence or incompetence of the venous valves, venous collaterals, and increased venous pressure of renal vein [2]. Similar to varicocele, there is also no consensus available on the etiology of varicose veins. However, it has been shown that valvular insufficiency may have a great impact on this pathological condition [2],[3],[4].

Lower limp varicose vein is a common problem, which presents with pain, cramps, and venous ulcers in legs. Although the incidence of varicose veins demonstrates variability based on the age of onset and location, in adult populations it is seen in 32% of women and 40% of men. In the vast majority of cases, the venous insufficiency was seen at the saphenofemoral junction (SFJ) or at major saphenous vein [5].

Valvular incompetence has been clearly shown to be the major underlying possible etiologic factor in the pathogenesis of both varicocele and venous insufficiency [6],[7].

The aim of this study was to evaluate the possible relationship between varicocele and saphenofemoral insufficiency in patients diagnosed with primary varicocele.


  Patients and methods Top


The current cross-sectional study included 40 patients with the primary diagnosis of varicocele, with age ranging from 20 to 60 years (the study group) and another 40 age-matched healthy adults (the control group). The study group included patients referred to the Department of Andrology, Faculty of Medicine, Ain Shams University, with scrotal pain or primary infertility. Healthy fertile controls were recruited from general public. None of the men in the control group were diagnosed with varicocele on the basis of physical and radiological examination.

History taking and general examination were performed, including height and weight measurement, and BMI was calculated for all participants. The participants were considered obese if they exceeded a BMI of 30.0 [8].

Varicocele was diagnosed by means of observation and palpation of each spermatic cord in standing position before and during a Valsalva maneuver. All physical examinations were performed by expert andrologists working at the Department of Andrology, Ain Shams University. In addition, scrotal duplex and lower extremity venous duplex were performed by the same radiologist with GE Logic 9 (GE Medical Systems, Milwaukee, Wisconsin, USA). The transverse diameter of the biggest vein in the pampiniform plexus was measured three times using a transducer probe with a frequency of 7.5-10 mHz during normal breathing and Valsalva maneuver. The arithmetic mean value of diameters measured was used for the assessment. Patients who had a spermatic vein larger than 3.0 mm or showed reverse flow during the Valsalva maneuver were considered as having varicocele. The reflux time in venous lower extremity duplex was used for the evaluation of the SFJ. A retrograde flow lasting longer than 0.5 s during normal breathing or at the Valsalva maneuver at the SFJ was considered diagnostic for SFJ insufficiency.

Varicocele was graded on the basis of the degree of reflux into three different groups: grade I (brief) reflux lasts less than 1 s and is considered physiologic; grade II (intermediate) reflux lasts 1-2 s and decreases during the Valsalva maneuver and then disappears before the end of the maneuver; and grade III (permanent) reflux lasts more than 2 s and has a plateau aspect throughout the Valsalva maneuver [9].

Semen analyses were performed for all patients in the study group.

All men in the control group were fertile (had one child or more) and were not diagnosed with varicocele on the basis of physical and radiological examination. Patients with past medical history of inguinal or scrotal surgery were excluded from the study due to the possible effects on spermatic veins.

Statistical analysis

SPSS for Windows version 12 (SPSS 12.0 Software, SPSS Inc., Chicago, IL) and the χ2 -test were used. The results were reported as mean ± SD, and a P value less than 0.05 was considered to be statistically significant.


  Results Top


The mean age of the study group and the control group was 34.3 ± 8.695 and 34.85 ± 6.815 years, respectively. The difference was not statistically significant (P = 0.75).

Sixteen (40%) of 40 patients and 29 (72.5%) of 40 controls were obese based on the BMI. There was no significant difference between the two groups as regards weight (P = 0.26) and smoking (P = 0.245) [Figure 1].{Figure 1}

Twenty-five participants in the study group had SFJ reflux (62.5%) compared with 11 participants in the control group (27.5%). In the study group, 17/25 (68%) patients with both varicocele and saphenofemoral insufficiency had grade III varicocele, 7/25 (28%) had grade II, and 1/25 (4%) had grade I varicocele as diagnosed by means of radiological examination. The patients with primary varicocele had a statistically significantly (P = 0.02) higher rate of SFJ insufficiency when compared with the control group, with increased incidence in higher grades of varicocele.

Of the 40 patients, 10 patients had recurrent varicocele; all of them were seen to have SFJ reflux on Doppler ultrasonography (US) (100%). Patients with recurrent varicocele were more likely to have SFJ reflux when compared with patients with nonrecurrent varicocele and the difference was statistically significant (P = 0.014) [Table 1],[Table 2] and [Table 3].
Table 1: The SFJ reflux in both study and control groups

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Table 2: The relation between grading of varicocele and SFJ reflux

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Table 3 Comparison between the study and control groups of patients according to their height

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  Discussion Top


Varicocele, commonly found in adolescents and young adults (15% in the male population and 37% in subfertile patients), is a dilation and tortuosity of the testicular veins and the pampiniform plexus, resulting from the increased pressure and retrograde flow in the pampiniform plexus and its drainage vein [1],[10]. Many proposed theories concerning the etiopathogenesis of the varicocele and varicose veins are based on an anatomic standpoint. The veins contain valves, which help in preventing retrograde blood flow. Its damage results in increased pressure transmitted to the vein and thus causes retrograde blood flow [11],[12].

A study demonstrated that a left varicocele may be a bilateral disease caused by incompetence of the one-way valves in the internal spermatic veins, associated with persistent pathological hydrostatic pressure in the long vertical spermatic veins and venous bypasses [13]. Another study by Yetkin et al. [14] has demonstrated that patients with coronary artery ectasia had an increased prevalence of varicocele compared with patients with other coronary artery diseases. Moreover, the increased prevalence of peripheral varicose veins has been reported with coronary artery ectasia by Androulakis et al. (2004) [15].

Kilic et al. (2007) [16] reported that varicocele is associated with an increased prevalence of peripheral varicose veins. Moreover, previous studies have shown a relationship between varicocele and valvular incompetence of the SFJ, which contributes to the formation of peripheral varicose veins [17],[18]. Sakamoto and Ogawa (2008) [19] concluded that varicoceles, especially bilateral varicoceles, may be associated with underlying venous abnormalities.

In the study by Koyuncu et al. (2011) [20], 36 of 70 participants (51.35%) had insufficiency in the SFJ in the study group, whereas eight of 30 patients (26.6%) had insufficiency in the control group.

In the current study, we have shown the association between varicocele and SFJ insufficiency, both of which may occur due to valvular incompetence. The current study also showed that obesity, increasing height, prolonged smoking, and smoking may be risk factors for both varicocele and varicose veins which has been demonstrated in other studies [21-24]. This may be explained by weakness of blood vessels and incontinence of valves.

Although 100% of patients with recurrent varicocele had SFJ reflux, the number of studied cases was too low (n = 10). Therefore, it cannot be concluded that all patients with recurrent varicocele are suspected as having SFJ reflux, unless a larger number of participants are studied. The high rate of occurrence of SFJ insufficiency among patients with recurrent varicocele might be explained by a higher predisposition of some individuals to the recurrence of their varicocsities due to congenital weakness or absence of valves of blood vessels. To the best our knowledge this is the first study to investigate the incidence of SFJ reflux among recurrent varicocele patients.

With respect to all these findings, we believe that varicocele may not be a local disease in all of the cases, but it may be a symptom of systemic venous insufficiency. Patients with varicocele, especially those with high-grade or recurrent varicocele, must be examined for the possibility of associating SFJ insufficiency. Early detection of SFJ insufficiency might prompt early intervention and prevent possible complications.


  Conclusion Top


The results of the present study showed that the incidence of SFJ reflux increases in individuals with varicocele, with a higher incidence in cases of recurrent varicocele. Depending on the common presence of valvular insufficiency, we believe that the presence of SF insufficiency should be investigated in the young population suffering from varicocele, especially if recurrent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Graif M, Hauser R, Hirshebein A, Botchan A, Kessler A, Yabetz H. Varicocele and the testicular-renal venous route: hemodynamic Doppler sonographic investigation. J Ultrasound Med 2000; 19 :627-631.  Back to cited text no. 1
    
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Labropoulos N, Leon M, Nicolaides AN, Giannoukas AD, Volteas N, Chan P. Superficial venous insufficiency: correlation of anatomic extent of reflux with clinical symptoms and signs. J Vasc Surg 1994; 20 :953-958.  Back to cited text no. 3
    
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Evans CJ, Fowkes FG, Ruckley CV, Lee AJ. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. J Epidemiol Community Health 1999; 53 :149-153.  Back to cited text no. 5
    
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Yetkin E, Kilic S, Acikgoz N, Ergin H, Aksoy Y, Sincer I, et al. Increased prevalence of varicocele in patients with coronary artery ectasia. Coron Artery Dis 2005; 16 :261-264.  Back to cited text no. 14
    
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Androulakis AE, Katsaros AA, Kartalis AN, Stougiannos PN, Andrikopoulos GK, Triantafyllidi EI, et al. Varicose veins are common in patients with coronary artery ectasia. Just a coincidence or a systemic deficit of the vascular wall?. Eur J Vasc Endovasc Surg 2004; 27 :519-524.  Back to cited text no. 15
    
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Kiliç S, Aksoy Y, Sincer I, Oðuz F, Erdil N, Yetkin E. Cardiovascular evaluation of young patients with varicocele. Fertil Steril 2007; 88 :369-373.  Back to cited text no. 16
    
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Ciaccio V, Ficola F, Ceccarelli F, Capodicasa E. Assesment of sapheno-femoral junction continence in 42 patients with primary varicocele. Minerva Chir 1995; 50 :469-473.  Back to cited text no. 18
    
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Sakamoto H, Ogawa Y. Is varicocele associated with underlying venous abnormalities? Varicocele and the prostatic venous plexus. J Urol 2008; 180 :1427-1431.  Back to cited text no. 19
    
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21.
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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