25 Varicocele |
167 |
Semen Analysis
Patients with suspected infertility should have an appropriately collected semen analysis and then have it repeated. The sample should be obtained with self- stimulation, abstinence period of 2–5 days, and no lubrication. Two samples should be obtained at least 4 weeks apart. Samples should be examined with microscopic examination by a skilled technician (Table 25.1). Critical components of the semen analysis include:
Physical Examination
A physical examination for patients with pain and infertility is very helpful for diagnosis. This should include a general examination, as well as focused exam on the genitourinary organs [2]:
•\ General appearance (congenital abnormalities, secondary sex characteristics) •\ Body habitus and gynecomastia
•\ Abdomen and inguinal areas for scars
•\ Phallic examination (circumcision status, meatal opening) •\ Examination of the vas deferens (unilateral or bilateral) •\ Testicular examination (size and consistency)
•\ Epididymal examination (dilated or fat)
•\ Cord examination (varicoceles, including grade or hernias) •\ Digital rectal examination
Table 25.1 WHO 2010 semen parameters [4]
|
World Health Organization |
|
Semen parameter |
2010 values |
Abnormality |
Volume (mL) |
1.5–6 |
|
Total sperm count (TSC) |
39 |
Azoospermia (TSC = 0) |
(million) |
|
Severe Oligospermia |
Concentration (million/mL) |
15 |
(TSC<5 millions) |
|
|
Oligospermia (TSC<15 millions) |
Progressive motility (%) |
32 |
Asthenospermia |
|
|
|
Total motility (%) |
40 |
|
Normal morphology (%) |
4–14% |
Teratozoospermia |
(strict) |
|
|
|
|
|
Vitality (%) |
58 |
|
Leukocyte count (million/ |
<1.0 |
|
mL) |
|
|
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N. Punjani and M. Goldstein |
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Proper Varicocele Examination |
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|
•\ |
Patient should be in a quiet room and heating pad placed on the scrotum (both a |
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|
cold room and anxiety may make examination challenging) |
|
•\ |
Examination needs to be completed both supine and standing |
|
•\ |
Testicular size should be estimated with an orchidometer |
|
•\ |
After visualization for grossly dilated veins, the scrotum should be squeezed |
|
|
between ngers above the testicle in the area of the cord. This should be repeated |
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with Valsalva |
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•\ |
Any veins should be palpated and felt as patient changes from standing to supine; |
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abnormal veins will collapse and normal veins will stay palpable |
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•\ |
The exam should be repeated while supine |
|
•\ |
Grading (modi ed from Dubin and Amelar) |
|
–– Grade 1—palpable impulse with Valsalva maneuver
–– Grade 2—palpable impulse with Valsalva maneuver and palpable tortuosity of cord veins
–– Grade 3—visible impulse on Valsalva and when upright without Valsalva
Grade 3a—just visible
Grade 3b— lls most of the hemiscrotum
Grade 3c— lls entire scrotum (Fig 25.1).
Fig. 25.1 Diagram illustrating a grade 3 varicocele