Varicocele

Definition

Epidemiology

• Varicoceles do not spontaneously regress.
• Most appear after age 10 and progress through puberty, peaking at Tanner stage 3.
• ~85% of men with varicocele in population-based studies have fathered children, so the individual impact on paternity is variable.

Anatomy & Pathogenesis

• The left internal spermatic vein drains into the left renal vein at a right angle and is longer; the right drains obliquely into the inferior vena cava
• This geometry creates higher hydrostatic pressure on the left, predisposing to venous valve incompetence
• The "nutcracker phenomenon" (compression of the left renal vein between the aorta and superior mesenteric artery) contributes in some cases

1. Elevated intratesticular temperature — disruption of countercurrent heat exchange in the pampiniform plexus (primary/most accepted theory)
2. Oxidative stress — higher ROS in seminal fluid → increased sperm DNA fragmentation
3. Venous stasis/hypoxia — pooling leads to toxin accumulation and hypoperfusion
4. Hormonal dysfunction — pituitary-gonadal axis disruption
5. Reflux of renal/adrenal metabolites via internal spermatic vein
6. Elevated apoptosis-associated microRNA in seminal fluid

Clinical Features

• "Dragging feeling" or dull ache in the scrotum, typically worse at end of day or with exertion
• "Bag of worms" — classic tactile description of the dilated venous plexus
• May be asymptomatic (incidentally discovered)
• Testicular atrophy — affected testis may be smaller and softer; progressive atrophy is documented

Grading (Dubin-Amelar / Clinical System)

Examine standing and supine. Veins should decompress in the supine position — failure to decompress (especially on the right) warrants imaging to rule out abdominal/pelvic mass.

Investigations

• Physical examination: Primary diagnostic tool
• Colour Doppler Ultrasound (CDUS): Used when examination is uncertain; detects retrograde blood flow and vein diameter; also assesses testicular volume
• Semen analysis: Abnormalities in concentration, motility (most profound), and morphology
• Venography: Gold standard for anatomical mapping but reserved for interventional planning

Effects on Fertility

• Semen parameters are poorer in men with varicocele vs. fertile population (WHO, 1992)
• Testicular atrophy progresses over time if untreated
• Sperm DNA fragmentation is elevated
• In adolescents, testicular volume discrepancy ≥20% between the two testes is a key surgical trigger

Treatment

Indications for intervention

• Adult: Palpable varicocele + abnormal semen parameters + subfertility
• Adolescent: Testicular volume discrepancy ≥20% on ultrasound; if volumes are stable and symmetric → annual surveillance ultrasound
• Symptomatic (pain/discomfort) regardless of fertility status

Surgical approaches

Outcomes

• Semen parameters (concentration, motility, morphology)
• Pregnancy rates and live birth rates
• Sperm DNA fragmentation
• Allows couples to step down to less invasive ART when indicated

Recent Evidence

• [PMID 38877692] — Meta-analysis (2024): Varicocele repair improves sperm parameters, FSH, and LH in infertile males with azoospermia
• [PMID 39776560] — Systematic review (2025): Varicocele repair is supported for severe oligoasthenoteratozoospermia (OAT syndrome) across multiple published guidelines

Fournier's Gangrene (FG)

Definition

Epidemiology

• Classically affects men ≥45 years, but women account for 10–25% of cases
• Diabetes mellitus present in 32–66% of patients
• Chronic alcohol abuse in 25–50%
• Can occur in previously healthy, immunocompetent individuals

Sources / Aetiology

Microbiology

• Gram-positive aerobes: Streptococcus pyogenes, Staphylococcus aureus
• Gram-negative aerobes: Escherichia coli, Klebsiella, Pseudomonas
• Anaerobes: Bacteroides spp., Clostridia, Corynebacteria

Pathophysiology

1. Initial focus → cellulitis at perineum/perianal region
2. Bacteria cause microthrombosis of subcutaneous vessels → ischaemia
3. Tissue necrosis along fascial planes (Dartos, Colles, Buck's, Scarpa's fascia)
4. Crepitus — from gas-forming organisms tracking through fasciae
5. Disease extent is far greater than visible skin findings suggest
6. Rapid progression to bacteraemia → sepsis → multi-organ failure → death

• Urogenital source: spreads posteriorly along Buck's and Dartos fascia → Colles fascia; limited at the anal margin by Colles fascia attachment to the perineal body
• Anorectal source: spreads to perianal skin; can extend anteriorly
• Both can spread to the anterior abdominal wall, potentially reaching the clavicles

The testes are usually spared — their blood supply originates intra-abdominally from the gonadal vessels, not from local fascial vessels.

Clinical Features

Early (cellulitis phase)

• Genital/perineal pain (65%) — often out of proportion to visible findings ⚠️
• Pruritus, lethargy, fever (may be afebrile on arrival)
• Swelling (65%), erythema (35%)
• Up to 40% initially have no localized symptoms — only pain

Advanced

• Crepitus of inflamed tissues (pathognomonic — gas-forming organisms)
• Purple/black bullae and necrotic patches
• Foul-smelling necrotic lesions with grey skin discolouration
• Signs of severe systemic illness out of proportion to visible local extent
• Rapid progression from genitalia → perineum → abdominal wall (can occur within hours)

Diagnosis

Imaging (when diagnosis uncertain)

LRINEC Score (Laboratory Risk Indicator for Necrotizing Infection)

Management

FG is a surgical emergency — triad of:

1. Resuscitation

• Aggressive IV fluid resuscitation, haemodynamic stabilisation
• ICU admission postoperatively

2. Broad-spectrum antibiotics (empiric, immediate)

• Piperacillin-tazobactam 3.375–4.5 g IV q6h OR imipenem 1 g IV q24h OR meropenem 500 mg–1 g IV q8h
• Plus vancomycin (MRSA coverage)
• Add clindamycin 600–900 mg IV q8h or metronidazole 500 mg IV q8h (anaerobic synergy/toxin suppression)

3. Surgical debridement (cornerstone)

• Wide aggressive debridement of all nonviable tissue to healthy, bleeding margins
• Extent of disease is invariably greater than external appearance — do not be conservative
• Average 3–4 return trips to the operating room required (second look at 24–48 hrs mandatory)
• Testicles are almost always spared (intra-abdominal blood supply)
• Urinary diversion (suprapubic catheter) or fecal diversion (colostomy/endorectal tube) as needed
• Negative pressure wound therapy (VAC) — reduces hospitalisation time, accelerates wound healing
• Split-thickness skin grafting for large tissue defects post-infection control

4. Adjunctive therapies

• Hyperbaric oxygen (HBO): pre- and post-operative; several groups report favourable results but evidence shows no improvement in overall mortality — use is controversial
• Reconstructive surgery: staged approach after infection is fully controlled

Severity Scoring Tools

Prognosis & Mortality

• Mortality historically reported 3–67%
• Contemporary estimates: 12–30%
• Historical reports as high as 67% (Schwartz's Surgery)
• Key predictors of death: age >60 and complications during treatment
• Survivors face months–years of disability; sexual dysfunction ~65%
• Long-term multidisciplinary follow-up required

Recent Literature (2024–2026)

• [PMID 41439154] — Umbrella review (2026, Eur Urol Open Sci): Müssgens et al. define the standard of care in Fournier's gangrene
• [PMID 38879239] — Review (2024): Multidisciplinary management emphasised
• [PMID 40455358] — Review (2025, Curr Urol Rep): Modern management update