Associate Professor Wollongong University Graduate School of Medicine
Introduction: The etiology of varicocele is thought to be related to incompetence of the gonadal vein. Epidemiological studies have shown that Left Common Iliac Vein Compression (LCIVC) =25% occurs in 22-35% of the general population. The objective of this study was to compare the incidence and severity of LCIVC in men with a varicocele with the published incidence in asymptomatic men, document the incidence of left gonadal incompetence and provide a possible explanation for varicocele treatment failure. Methods: Men presenting at our practice with a varicocele were enrolled into this study. Ethics approval was obtained. All participants underwent a Duplex Ultrasound of the pelvic veins. The degree of LCIVC was grouped into =25% (significant compression) and =50% (severe compression). The results were compared to a vascular epidemiological study of 272 asymptomatic men (Cheng et al 2017), by Chi-squared analyses. Degree of compression was analyzed for association with Grade of varicocele by Kruskal-Wallis ANOVA test. Results: 80 men with varicoceles completed the investigations. Mean age of the cohort was 39.5 years. In our study group, 91.2% men had a LCIVC =25% (73/80) compared to the expected incidence in asymptomatic men of 29.4% (80/272) [?2=96.2; p<0.001]. The study also showed that 67.5%% (54/80) had LCIVC =50% (severe) compared to the expected incidence in asymptomatic men of 6.9% (19/272) [?2=137; p<0.0001]. Only 23% of men had incompetent gonadal veins (19/80). 16% of men with varicoceles had retrograde flow through the left internal iliac vein. 8.8% (7/80) men presented with recurrent varicocele and all had severe LCIV compression =50%. There was no significant correlation between WHO varicocele grade and degree of compression (Kruskal-Wallis one-way ANOVA H=3.26, p=0.196). Conclusions: This is the largest study to show that men with varicoceles have a significantly higher incidence of LCIVC =25% (significant) and LCIVC =50% (severe) than asymptomatic men. Increased pelvic venous pressure from LCIVC can lead to retrograde flow through the left internal iliac vein (16%). The high incidence of LCIVC in men with a varicocele suggests that a varicocele is an “escape” vessel for increased pelvic venous pressure. The majority of men in our cohort did not have a demonstrable incompetent gonadal vein (23%). This would make embolization difficult, and ligation unlikely to provide long term benefit if there was a separate pelvic feeding vessel. Severe LCIV compression (=50%) is associated with DVT and pelvic venous congestion. Men with varicoceles should be further investigated with a pelvic duplex ultrasound. All of the men presenting with recurrent varicocele after embolization had severe LCIV compression. Although these results are significant, larger studies are needed to confirm these findings. SOURCE OF Funding: None
