ANSWER:
Infertility is a significant worry for couples worldwide, with male factor infertility accounting for roughly 40–50% of cases. Varicocele is one of the most common reasons for male infertility, and the dilatation and tortuosity of the veins within the spermatic cord distinguish it. It affects about 15% of the general male population and is more common among infertile males, where the frequency ranges from 35% to 40%. This paper aims to examine varicocele as the most likely cause of infertility symptoms in a 23-year-old male with oligospermia and a palpable “bag of worms” sensation in the left spermatic cord.
A varicocele is the abnormal dilatation of the veins that drain the testicles, known as the pampiniform plexus. Because of the physical structure of the left testicular vein, which empties into the left renal vein at a right angle, it is more susceptible to increased venous pressure on the left side. Increased pressure within the dilated veins can compromise testicular blood flow, raise the scrotal temperature, and modify the testicular microenvironment, resulting in testicular dysfunction and infertility.
Clinical Presentation and Physical Examination: The occurrence of oligospermia (low sperm count) in the presented case suggests decreased spermatogenesis, a typical finding in varicocele. The “bag of worms” sensation felt when palpating the left spermatic cord is a common physical finding in varicocele. The thread has a particular feel due to the dilatation and tortuosity of the veins, distinguishing it from other disorders such as hydrocele, testicular torsion, and spermatocele.
Differential Diagnosis: When distinguishing varicocele from other disorders, it is critical to examine the clinical presentation and physical examination results. Hydrocele is improbable in this situation because the scrotum and testes are typical in size, and there are no palpable lumps. Acute testicular pain, swelling, and tenderness are common symptoms of testicular torsion, which are absent in this patient. Spermatocele, defined as a cystic mass containing sperm, would manifest as a discrete palpable mass, which is not the situation here.
Diagnostic Evaluation: Varicocele can be diagnosed using a variety of diagnostic modalities, including scrotal ultrasonography and Doppler imaging. Scrotal ultrasonography can detect dilated veins and determine the severity of varicocele. Doppler ultrasound aids in measuring blood flow inside the afflicted veins, allowing varicocele to be classified into different classes based on severity.
Impact on Male Fertility: The underlying mechanisms by which varicocele impacts fertility remain unknown. Several hypothesized ideas, however, include testicular hypoxia, elevated scrotal temperature, adrenal and renal metabolite reflux, oxidative stress, and hormonal abnormalities. These factors disrupt spermatogenesis, lower sperm quality (e.g., decreased motility and morphology), and increase DNA damage inside the spermatozoa, ultimately leading to male infertility.
Treatment Options: Varicocele treatment is appropriate in males with clinical varicocele and abnormal sperm parameters or infertility. The treatment’s primary purpose is to increase sperm parameters and fertility results. There are now two main treatment options: surgical repair and radiological intervention. Varicocelectomy is a surgical procedure that involves ligation or occlusion of the dilated veins to reroute blood flow and reduce venous pressure. Radiological procedures, such as percutaneous embolization, use minimally invasive techniques to achieve similar results.
Conclusion: In the described case of a 23-year-old male with infertility symptoms, oligospermia, and a palpable “bag of worms” sensation in the left spermatic cord, varicocele is the most likely disease. Varicocele, defined by the dilatation and tortuosity of veins within the spermatic line, is a significant cause of male infertility. Prompt identification and treatment of varicocele are essential for enhancing sperm parameters and reproductive outcomes in affected patients.
References:
SC Esteves, R Miyaoka, M Roque, and Agarwal. A systematic review and meta-analysis of the outcomes of varicocele repair in men with nonobstructive azoospermia. Asian Journal of Androl. 2016;18(2):246-253. doi:10.4103/1008-682X.169545
J.I. Gorelick and M. Goldstein. Fertility loss in men with varicocele. Fertility and Sterility. 1993;59(3):613-616. doi:10.1016/s0015-0282(16)55782-7
QUESTION:
What is the most likely condition a 23-year-old healthy man with oligospermia, a ‘bag of worms’ feel in the left spermatic cord, and normal testes and scrotum is expected to have?