Predictors of Pain Resolution After Varicocelectomy For Painful Varicocele
Predictors of Pain Resolution After Varicocelectomy For Painful Varicocele
Predictors of Pain Resolution After Varicocelectomy For Painful Varicocele
2011 AJA, SIMM & SJTU. All rights reserved 1008-682X/10/11 $32.00
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ORIGINAL ARTICLE
INTRODUCTION
A varicocele is a dilation of the scrotal portion of the pampiniform
plexus and internal spermatic venous system.1 It accounts for ,35%
of cases of primary male infertility and is considered to be the most
common cause of male infertility.2 Surgical repair of a varicocele is
usually performed in patients complaining of infertility. About 210%
of men with varicocele complain of pain, mainly in the scrotum or
inguinal area.3 Conservative management may be offered to these
patients, including limitation of physical activities, scrotal elevation
and treatment with non-steroidal anti-inflammatory analgesics.
However, these often do not contribute to pain management.4
Varicocelectomy is an alternative treatment for patients with painful
varicocele who show no improvement after conservative management.5 Currently, few clinical studies have evaluated which patients
with scrotal pain require a varicocelectomy and which clinical characteristics associated with varicocele can predict surgical outcomes.3,69
Moreover, the success rates of varicocelectomy for painful varicocele
vary among studies. Symptom improvement has been reported in
.80% of patients after the surgical repair of a painful varicocele;3,6,9,10
however, Biggers and Soderdahl5 reported a relatively low rate of
improvement (48%). The variety of surgical success rates for treating
painful varicocele and the lack of predictive parameters for surgical
outcomes make it difficult for urologists treating patients with painful
varicocele. In this study, we examined the effectiveness of surgical
repair in patients with painful varicocele, and we examined the
Department of Urology, Pusan National University School of Medicine, Medical Research Institute, Pusan National University, Busan 602-739, Korea
*These two authors contributed equally to this work.
Correspondence: Dr N C Park (joon501@pusan.ac.k)
Received: 15 February 2010; Revised: 17 April 2010; Accepted: 2 July 2010; Published online: 22 November 2010
Total (n553)
25.7 (1267)
17 (32.1%)
21 (39.6%)
15 (28.3%)
21.9 (16.027.2)
4 (7.5%)
31 (58.5%)
18 (34.0%)
1 (1.9%)
8 (15.1%)
44 (83.0%)
48 (90.6%)
5 (9.4%)
21 (43.8)
27 (56.2)
9.5 (172)
34 (64.2%)
19 (35.8%)
23 (43.4%)
23 (43.4%)
2 (3.8%)
5 (9.4%)
44 (83.0%)
9 (17.0%)
Table 2 Relationships between preoperative characteristics and postoperative improvements in pain according to univariate and multivariate
analyses
Multivariate analysis
Factors
Failure (n (%))
P value
P value
Age (years)
,20
2029
o30
BMI (kg m22)
,18.0
18.022.9
o23.0
Grade
I
II
III
Location
Unilateral
Bilateral
Testis volume difference (ml)c
,3
o3
Duration of pain (months)
,6
o6
Quality of pain
Dull
Dragging
Throbbing
Sharp
Surgical technique
Inguinal
Subinguinal
7 (41.2)
13 (61.9)
8 (53.3)
9 (52.9)
7 (33.3)
6 (40)
1 (5.9)
1 (4.8)
1 (6.7)
1 (25)
17 (54.8)
10 (55.5)
3 (75)
14 (45.2)
5 (27.8)
0 (0)
0 (0)
3 (16.7)
1 (100)
4 (50)
23 (52.3)
0 (0)
3 (37.5)
19 (43.2)
0 (0)
1 (12.5)
2 (4.5)
25 (52.1)
3 (60)
21 (43.7)
1 (20)
2 (4.2)
1 (20)
9 (42.8)
16 (59.3)
11 (52.4)
10 (37.0)
1 (4.8)
1 (3.7)
15 (44.1)
13 (68.4)
19 (55.9)
3 (15.8)
0 (0)
3 (15.8)
13 (56.5)
12 (52.2)
1 (50)
2 (40)
9 (39.1)
9 (39.1)
1 (50)
3 (60)
1 (4.4)
2 (8.7)
0 (0)
0 (0)
24 (54.4)
4 (44.5)
18 (40.9)
4 (44.5)
2 (4.6)
1 (11.0)
0.367
0.761b
0.244a
0.042b
0.676a
0.982b
0.716a
0.872b
0.724a
0.882b
0.004a
0.002b
0.874a
0.924b
0.374a
0.169b
No. of patients
50
Mean age (years)
20.7
Duration of pain
13.8
(months)
Preoperative
19 (38)
conservative
therapy (n (%))
Location (n (%))
Left
NA
Bilateral
NA
Right
NA
Grade (n (%))
I
NA
II
NA
III
NA
Quality of pain
Dull
NA
Dragging
NA
Throbbing
NA
Sharp
NA
Surgical techniques (n (%))
Retroperitoneal
50 (100)
Inguinal
0 (0)
Subinguinal
0 (0)
Laparoscopic
0 (0)
0 (0)
Pain resolution (n (%))
Complete
24 (48)
Partial
0 (0)
Failure
26 (52)
Duration of followNA
up (months)
Suggested
NA
predictive
parameter for
success
10
13
Present study
35
25.7
17.8
82
NA (840)
NA
103
21
11.6
87
26
16
121
21.8
17.3
38
NA (1416)
NA
237
23.7
11.2
53
25.7
9.5
35 (100)
82 (100)
103 (100)
87 (100)
56 (46.3)
NA
237 (100)
53 (100)
30 (85.7)
5 (14.3)
0 (0)
70 (85.4)
12 (14.6)
0 (0)
NA
NA
NA
82 (94.3)
5 (5.7)
0 (0)
NA
NA
NA
NA
NA
NA
202 (85)
35 (15)
0 (0)
48 (90.6)
5 (9.4)
0 (0)
1 (2.9)
16 (45.7)
18 (51.4)
10 (14.3)
34 (48.6)
26 (37.1)
0 (0)
40 (38.8)
63 (61.2)
17 (19.5)
34 (39.1)
36 (41.4)
10 (8.3)
57 (47.1)
54 (44.6)
0 (0)
9 (23.7)
29 (76.3)
9 (3.8)
67 (28.3)
161 (67.9)
1 (1.9)
8 (15.1)
44 (83)
22 (63)
2 (6)
9 (26)
2 (6)
NA
NA
NA
NA
22 (21.4)
48 (46.6)
0 (0)
33 (32)
42 (48.3)
14 (16.1)
25 (28.7)
6 (6.9)
20 (16.5)
44 (36.3)
0 (0)
19 (15.7)
NA
NA
NA
NA
NA
NA
NA
NA
23 (43.4)
23 (43.4)
2 (3.8)
5 (9.4)
10 (28.6)
0 (0)
24 (68.6)
1 (2.8)
0 (0)
0 (0)
0 (0)
82 (100)
0 (0)
0 (0)
40 (38.8)
41 (39.8)
22 (21.4)
0 (0)
0 (0)
87 (100)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
28 (23.1)
93 (76.9)
0 (0)
0 (0)
0 (0)
24 (63.2)
0 (0)
14 (36.8)
0 (0)
0 (0)
0 (0)
237 (100)
0 (0)
0 (0)
0 (0)
44 (83)
9 (17)
0 (0)
0 (0)
30 (86)
1 (3)
4 (11)
10.9
72 (87.8)
4 (4.9)
6 (7.3)
NA
81 (78.6)
10 (9.7)
12 (11.6)
NA
72 (82.8)
8 (9.2)
7 (8)
36
74 (61.2)
27 (22.3)
20 (16.5)
4.7
26 (68.4)
4 (10.5)
8 (21.1)
6
203 (85.6)
15 (6.3)
19 (8.1)
3
28 (52.8)
22 (41.5)
3 (5.7)
12.4
Quality of pain
Grade of
varicocele
Quality of pain
NA
Surgical
techniques
None
patients with a long period (o3 months) of pain was higher than in
those patients with a shorter duration of pain. However, there was a
difference in the duration criteria between our (6 months) and
Altunoluks (3 months) study. Thus, further study is required to substantiate the association of pain duration before surgery with the
postoperative surgical outcome.
The reported failure rate according to surgical technique varies
among studies, and no significant differences have been observed.3,7,13
Only one study8 has shown a significant difference in the postoperative
success rate between patients who underwent external spermatic vein
ligation and those who did not, suggesting that cremasteric muscle
ischemia may have a significant role as the cause of pain in varicocele.
However, no data in the published literature support this hypothesis.
We examined the difference in surgical success between inguinal and
subinguinal approaches, but no significant difference was observed.
However, we had only nine patients who underwent a subinguinal
procedure. Hence, additional studies are warranted to examine the
relationship between surgical procedure and pain resolution.
We did not observe any recurrent or persistent varicocele among the
patients without pain resolution, in accordance with the studies of
Yaman et al.6 and Altunoluk et al.9 It is thought that pain persistence
is probably not related to varicocele recurrence.
There are several important limitations to this study. First is the lack
of a randomized design and the small number of patients. Moreover,
the lack of an even distribution of patients for grade, location of
varicocele and operative technique (subinguinal versus inguinal)
may have resulted in bias. Second, this was not a prospective study.
Therefore, we assume that there was insufficient consideration of the
differences in pre- and postoperative symptoms or of other comorbidities. Finally, we did not use an internationally validated questionnaire and did not quantify the pain intensity.
In conclusion, our data suggest that varicocele ligation for pain is
successful when performed in properly selected patients in whom
conservative management has failed. In addition, there was a significant correlation between symptom improvement and a short duration
of pain before surgery.
AUTHOR CONTRIBUTIONS
NCP designed the study. HJP and SSL collected data, analyzed data,
interpreted the data and wrote the paper.
COMPETING FINANCIAL INTERESTS
The authors declare no competing financial interests.
Asian Journal of Andrology
ACKNOWLEDGMENTS
This study was supported by a Medical Research Institute Grant (2007-24) from
Pusan National University Hospital.
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APPENDIX
Questionnaire for the assessment of scrotal pain and treatment
outcome
Preoperative
Question 1: How long have you been suffering from scrotal pain?
a. less than 6 months
b. longer than 6 months
Question 2: How would you characterize your scrotal pain?
a. dull
b. dragging
c. throbbing
d. sharp
Postoperative
Question 3: How do you feel after surgery?
a. completely resolution of pain
b. partially resolved pain (greater than 70% reduction)
c. persistent pain or a less than 70% reduction