Link between lower extremity venous reflux and varicocele in adult male patients: A prospective study

Kamil Doğan; Ferit Çetinkaya; Ayşe Taş

doi:10.5606/e-cvsi.2024.1666

Abstract

Objectives

This study aimed to investigate the relationship between lower extremity venous reflux and varicocele in adult males.

Patients and methods

A total of 102 adult male patients (mean age: 42.7±15.5 years; range, 20 to 82 years) with complaints of burning, cramps, swelling with prolonged standing, and superficial varicose veins were enrolled in the prospective study between January 2023 and June 2023. All patients were subjected to bilateral lower extremity venous and scrotal Doppler ultrasonography.

Results

Varicocele was more frequently observed in individuals with left vena saphena magna (VSM) reflux compared to those without (p=0.001). Similarly, varicocele was more prevalent in individuals with left VSM insufficiency compared to those without (p=0.008).

However, there was no significant relationship between right VSM insufficiency, right VSM reflux, and pampiniform reflux on either side (p>0.05).

Conclusion

In patients with reflux in the left VSM, pampiniform reflux and varicocele are more frequently observed. This finding can provide valuable clues for the early diagnosis of varicocele, particularly for urologists, vascular surgeons, and radiologists.

Keywords:

Doppler ultrasound, varicocele, venous reflux

Introduction

Chronic venous insufficiency is a commonly encountered vascular disorder in the community.

Advancing age, obesity, pregnancies, prolonged periods of standing, positive family history, and Caucasian ethnicity are predisposing factors for chronic venous insufficiency.[1] Previous studies have proposed that chronic venous insufficiency shares similar pathogenesis with varicocele in males, emphasizing venous valve insufficiency, associated reflux, venous wall pathology, and May-Thurner syndrome as frequently suggested pathologies.[2-5]

Varicocele, observed in approximately 15% of the adult male population, has been identified as a major cause of infertility, affecting nearly 40% due to a decrease in sperm count and motility.[6] Diagnosis involves the palpation of dilated veins during physical examination or the demonstration of enlarged pampiniform veins through Doppler ultrasonography (USG), both playing a significant role.

This study aimed to investigate the potential connection between lower extremity venous reflux and varicocele in adult males.

Methods

A total of 102 adult male patients (mean age: 42.7±15.5 years; range, 20 to 82 years) presenting with burning, cramps, swelling with prolonged standing, and superficial varicose veins at the cardiovascular surgery outpatient clinic of the Ağrı Training and Research Hospital between January 2023 and June 2023 were enrolled in the prospective study. Patients with a history of venous thrombosis were excluded from the study (Figure 1).

After obtaining a medical history and conducting a physical examination, all patients were subjected to bilateral lower extremity venous and scrotal Doppler USG. A single radiologist performed measurements using a Toshiba Aplio 500 Ultrasound device (Canon Medical Systems USA, Inc., Tustin, CA, USA) during the same session (Figure 2). Measurements included diameter and reflux measurements of the vena saphena magna (VSM) at the junction level, as well as diameter and reflux measurements of bilateral pampiniform veins. The VSM reflux and pampiniform reflux were measured with the Valsalva maneuver. Standing measurements were taken for all patients. Reflux lasting more than 1 sec at the VSM junction level was considered positive.[7] Reflux flow lasting more than 1 sec along the course of the VSM at the thigh level following caudal decompression was considered VSM venous insufficiency. In scrotal Doppler USG, patients with a diameter of 3 mm or more on either side and reflux lasting more than 2 sec in the pampiniform plexus vein were considered to have varicocele, according to the 2019 guidelines published by the European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group.[8]

Statistical analyses

The data obtained from the study were analyzed using the IBM SPSS version 19.0 software (IBM Corp., Armonk, NY, USA). The Kolmogorov-Smirnov test was performed to assess normal distribution suitability. Descriptive statistics, including numbers and percentages, means, and standard deviations, were provided. The Mann-Whitney U test was employed to evaluate the relationship between two groups for measurement data that did not follow a normal distribution. The chi-square test was utilized to assess the relationship between categorical variables. A p-value <0.05 was considered statistically significant.

Results

The sociodemographic characteristics and medical histories of the patients are presented in Table 1. In terms of occupation, 37.3% were workers, 16.7% were farmers, and 12.7% were retirees. Among the patients, 57.8% smoked, and 2.0% consumed alcohol. Additionally, 2.9% had diabetes mellitus (DM), 11.8% had hypertension (HT), and 1.9% had benign prostatic hyperplasia (BPH).

None of the patients exhibited venous ulcers or infertility. Scrotal pain was reported in 13.7% of the patients. Additionally, among the patients, 34.3% presented with right VSM insufficiency, 30.4% with right VSM reflux, 46.1% with left VSM insufficiency, 42.2% with left VSM reflux, and 26.5% with pampiniform reflux. Varicocele was observed in 34.3% of the patients. The mean diameter of the right VSM was 5.2±2.2, the mean diameter of the left VSM was 5.8±2.6, the maximum VSM diameter was 6.4±2.7, and the mean diameter of the pampiniform vein was 1.3±1.8 (Table 2).

Pampiniform reflux was more prevalent in those with left VSM reflux compared to those without (p=0.001). Similarly, individuals with left VSM insufficiency exhibited a higher occurrence of pampiniform reflux than those without (p=0.006).

However, there was no significant relationship between right VSM insufficiency, right VSM reflux, and pampiniform reflux (p>0.05), as indicated in Table 3.

Varicocele was more frequently observed in individuals with left VSM reflux compared to those without (p=0.001). Similarly, varicocele was more prevalent in individuals with left VSM insufficiency compared to those without (p=0.008). However, there was no significant relationship between right VSM insufficiency, right VSM reflux, and pampiniform reflux on either side (p>0.05), as outlined in Table 4.

No significant relationships were found between the presence of pampiniform reflux and age, alcohol use, diagnosis of DM, diagnosis of HT, and diagnosis of BPH (p>0.05). Pampiniform reflux was more frequently observed in nonsmokers compared to smokers (p=0.005). Additionally, pampiniform reflux was more prevalent in individuals with scrotal pain compared to those without (p<0.001).

Similarly, no significant relationships were detected between the presence of varicocele and age, alcohol use, and HT diagnosis (p>0.05). However, individuals diagnosed with BPH exhibited a higher prevalence of varicocele compared to those without (p=0.01).

Varicocele was also more frequently observed in individuals with DM diagnosis compared to those without (p=0.04). Furthermore, individuals with scrotal pain had a higher prevalence of varicocele compared to those without (p<0.001).

Discussion

In our study, left pampiniform reflux was found to be statistically significantly higher in patients with left VSM reflux. This could be attributed to anatomical reasons, such as the left testicular vein taking a 90° angle with the renal vein and the cross-adjacency of the left iliac vein and the right iliac artery.[9] Chin et al.,[10] in their research involving 21 varicocele patients, were the first to demonstrate that May-Thurner syndrome (compression of the left iliac vein) causes varicocele.

Furthermore, a case report has demonstrated that May-Thurner syndrome could lead to varicocele by causing left internal iliac vein reflux.[11] Although our study suggests a significant association between varicocele and left venous reflux, the exact cause may be related to this condition. However, this study did not specifically investigate the presence of reflux in the internal iliac veins.

Another theory discussed in many previous studies regarding the relationship between venous reflux and varicocele is venous valve insufficiency as a shared etiology.[3,12,13] However, in our study, a statistically significant increase in varicocele was observed only in patients with venous reflux in the left VSM.

The relationship between varicocele and demographic data was investigated in our study, but no significant association was found. It is not surprising that varicocele is more prevalent in patients with scrotal pain complaints. In a study conducted by Owen et al.,[14] it was reported that scrotal pain accompanied varicocele in 10% of patients. On the other hand, none of the patients included in the study showed evidence of venous ulcers upon examination.

According to the report on varicocele and infertility published by the American Urological Association, even if patients diagnosed with varicocele do not complain of infertility, it is emphasized that sperm analysis should be performed. This is because patients may express a desire to have children in the future, and those with developed azoospermia should be treated.[15] Although none of the patients included in this study reported infertility complaints, all patients diagnosed with varicocele were referred to urology specialists for a thorough examination and sperm analysis, as they are considered potential candidates for secondary infertility. Additionally, patients with detected VSM reflux and dilation were treated with stripping, radiofrequency ablation, or medical follow-up (compression stockings and venoactive drugs).[16]

There are some limitations to this study. This study was planned with prospectively conducted Doppler measurements during the same session; however, sperm analysis and measurements of internal iliac vein reflux were not performed due to technical challenges. Additionally, the relatively low number of patients might limit the generalizability of the results, and conducting studies with larger sample sizes could yield more comprehensive outcomes.

In conclusion, in patients with reflux in the left VSM, pampiniform reflux and varicocele are more frequently observed on either side. This finding can provide a valuable clue for the early diagnosis of varicocele, particularly for urologists, vascular surgeons, and radiologists. Further extensive studies with a larger number of patients are needed in this regard.

Ethics Committee Approval: The study protocol was approved by the Ankara City Hospital Ethics Committee (date: 21.06.2023, no: 3577). The study was conducted in accordance with the principles of the Declaration of Helsinki.

Patient Consent for Publication: A written informed consent was obtained from each patient.

Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author Contributions: Idea/concept, design, control/ supervision, writing the article, critical review: F.Ç.; Data collection and/or processing, references and fundings, materials: K. D.; Analysis and/or interpretation, literature review: A.T.

Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding: The authors received no financial support for the research and/or authorship of this article.

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