Varicocele

00:02 Our topic here is varicocele.

00:04 What do varices mean to you? Engorgement of your veins.

00:08 Here we have a varicocele.

00:11 What’s happening? Dilation of veins, you must know the anatomy in greater detail here.

00:16 You must know about the pampiniform plexus due to increased venus pressure.

00:21 How does your increased pressure which is then – Well, the veins, what are they doing? That’s important for you to understand.

00:28 Are veins draining or supplying? Draining.

00:31 So if there’s increased pressure in the veins, then you’re having difficulty with the draining.

00:36 So now, what happens? Engorgement, right? Welcome to varicocele.

00:42 Concept first, then you plug in the diagnosis.

00:46 Most common cause of scrotal enlargement is varicocele.

00:50 Most common cause of scrotal enlargement, hence, know everything about varicocele.

00:57 What side? Almost always on the left side due to resistance to flow.

01:02 It’s important that you know the anatomy here.

01:05 The left testicular vein or gonadal vein drains into the left renal vein.

01:10 Can you picture that for me? Does that happen on the right side? No.

01:15 Okay, so pause.

01:18 On the left side, if the left gonadal vein or testicular vein has to drain into the left renal vein first, then it drains into your inferior vena cava.

01:26 My goodness, that’s a pretty long journey.

01:29 And so therefore, if at any point in time there is blockage, then you’re going to have engorgement and enlargement of the scrotum, left side.

01:37 Simple anatomy, clinical – Everything that you do in medicine between you and I or in general by yourself, make sure you give it a clinical tag.

01:45 If you don’t, then I don’t know, just leave it aside and come back to it.

01:50 Acute onset may indicate a thrombotic event.

01:53 Secondary to nephrotic syndrome or even renal cell carcinoma.

01:57 Keep that in mind.

01:58 Interesting? We’ve talked about this.

02:02 Nephrotic syndrome leaves you in what kind of state? Bleeding or hypercoagulable? Good, hypercoagulable.

02:10 Do you see as to how everything that you’ve learned is coming together now? Nephrotic syndrome, your losing antithrombin III.

02:17 Antithrombin III normally knocks out your? If you remember.

02:19 Thrombin.

02:21 So normally, it should control coagulation.

02:25 In nephrotic syndrome, if you remember, of all the coag factors, the one that you have memorized and, if you haven’t, do so.

02:31 Again, now, you lose antithrombin III.

02:36 And you're state of what? Hypercoagulabilty.

02:39 Where? Renal vein.

02:42 And what about renal cell carcinoma? Renal cell carcinoma, once again if it’s the left side, think about metastasis.

02:50 You’ve moved from stage one to stage two.

02:52 You’ve busted through the capsule and now you’re going to metastasize through the renal vein.

02:58 This is metastasis.

03:01 All these cancer cells, slowly moving.

03:04 It’s a gang passing through the renal vein.

03:07 And all of the sudden, on the left side, here comes gonadal.

03:10 Hey, what’s up? But the thing is, it’s a bully.

03:14 It stops the drainage of your gonadal vein So you’d stopped the drainage of your testicular vein or gonadal vein, welcome to varicocele.

03:24 Signs and symptoms that will then help you out to figure out what’s going on with your patient.

03:30 Next, well, if you’re decreasing the drainage, would you call this hyperemia or congestion? Yet another basic concept.

03:38 Congestion.

03:40 So congestion, may result in high temperatures.

03:43 What’s optimum temperature? How about 98.6 degrees Fahrenheit, 37 degrees Celsius? With all these increased heat, there’s every possibility that you may or may then become infertile.

03:56 So far so good.

03:58 Let’s keep going.

03:59 Diagnosis made by standing exam.

04:01 What? Yes, exactly right.

04:04 You can see this on gross examination with your eyes and the scrotum looks like it contains a bag of “worms”.

04:12 Why? Because the veins are engorged.

04:14 Can you picture that? Literally, the scrotum looks like a bag of worms.

04:19 Okay.

04:20 Hence, the standing exam.

04:22 Let’s keep going.

04:23 Inspect the bag of worms that are palpable and observe with? Make sure you know how to investigate properly.

04:29 A Doppler ultrasound.

04:31 It does not transilluminate.

04:33 That’s important.

04:34 It does not, because what’s in your vein? Blood.

04:38 Blood is thick and viscous, it will not transilluminate.

04:42 "Versus what, Dr. Raj?" Hydrocele.

04:46 Be careful.

04:48 They both have the suffix –cele.

04:50 Varicocele, hydrocele.

04:52 You pay attention to the prefix.

04:54 Varico-, blood.

04:56 Hydro-, fluid.

04:58 Which one of these will illuminate? Fluid, hydro-. Not varico- Are we clear? Let’s keep going.

05:05 So it does not transilluminate.

05:06 And management includes – Well, you have to – My goodness, you have to get rid of the congestion.

05:11 So there’s something called varicocelectomy or perhaps something called embolization.

05:16 On a Doppler ultrasound, you will find certain issues and with ultrasound, you would find as you see in the picture here, the bag of worms type of appearance.

05:27 Image shows several what’s known as your anechoic tubule.

05:31 What does that mean to you? Remember this doesn’t appear as being lucent and black, anechoic.

05:36 And the application they call a Doppler imaging in the same patient will show what? Bidirectional flow with anechoic tube.

05:44 Now, do you understand this is in the veins? Should the veins ever -- The fluid and the blood, should it ever move back and forth, back and forth? No. It’s always unidirectional.

05:54 Veins are always draining.

05:57 So if it’s blocked and you see bidirectional flow, that’s a pathology.

06:02 Full picture of varicocele.

06:03 Every single bullet point that I’ve gone through here, incredibly important.