DI LUIGI L

ROMANELLI, Francesco

English

Archivio della ricerca- Università di Roma La Sapienza

Varicocele and sports participation  International SportMed Journal, Vol. 9 No.3, 2008, pp.141-144, http://www.ismj.com  ISMJ International SportMed Journal  FIMS Position Statement  Varicocele and sports participation 1*Professor Luigi Di Luigi, MD, 2Dr Francesco Romanelli, MD 1Unit of Endocrinology, Department of Health Sciences, University of Rome, IUSM, Rome, Italy 2Unit of Andrology and Endocrinology, Department of Medical Pathophysiology, University La Sapienza, Rome, Italy  Introduction Varicocele is an abnormal dilatation of the pampiniform venous plexus that surrounds the testis resulting from venous incompetence of the spermatic veins 1.  Varicocele is the most frequent physical finding in infertile men and also is the most common andrological disease found during a male physical examination 2.   Varicocele occurs on the left side in 78-93% of cases, but it occurs more frequently as bilateral disease than previously documented. Varicocele is graded by an arbitrary scheme as grade I (small with palpable distension detected only during a Valsalva manoeuvre), grade II (moderate with easily palpable distension on upright examination), grade III (large with visible veins on upright examination).   *Professor Luigi Di Luigi, MD Professor Di Luigi is Professor of Endocrinology at the University of Rome “Foro Italico”, Rome, Italy.  He is Director of Department of Health Sciences and the Director of the Endocrinology Unit at the University.  Professor Di Luigi is the Vice-President of the Italian Federation of Sport Medicine (FMSI). His main research interests are: (a) the endocrine system, physical exercise and sport; (b) supplements and hormones in athletes; (c) physical activities and reproduction; (d) endocrine diseases and exercise, and (e) doping.  Professor Francesco Romanelli, MD Professor Romanelli is an Aggregate Professor of Endocrinology, Department of Medical Pathophysiology, University of Rome “La Sapienza”, Rome, Italy.  Main research interests are (a) endocrine involvement in sport sciences, (b) andrology and exercise, (c) testicular paracrinology, and, (d) arachidonic acid metabolites in endocrinology. Email address: francesco.romanelli@uniroma1.it Official Journal of FIMS (International Federation of Sports Medicine)  141                                                           *Corresponding author.  Address at the end of text. Prevalence of varicocele Varicocele has a high prevalence of 4% to 23% in the general male population, and 29% or higher in athletes 3, 4, representing the most frequent disease found in infertile men.  It has been detected in 35% (range 19-41%) of men with primary infertility and in 80% of men with secondary infertility (range 69-94%) 5, 6.  Epidemiological studies correlating sports and andrological diseases (e.g. varicocele) are rare.  Varicocele and sports participation  International SportMed Journal, Vol. 9 No.3, 2008, pp.141-144, http://www.ismj.com  Clinical symptoms and consequences Varicocele can be asymptomatic or induce testicular pain and the subjective feeling of a “bag of worms” around the testis.  Varicocele influences the quantitative and qualitative characteristics of seminal fluid.  The most common semen alterations observed in untreated subjects affected by varicocele are decreased motility (qualitatively and quantitatively), increased atypical spermatozoa, more immature cells, and reduced total number of spermatozoa.   The most accepted hypothesis to explain the pathophysiology of varicocele suggests different venous drainage between the left and right sides and a higher prevalence of absent venous valves on the left side. Multiple local mechanisms seem to be involved in varicocele development including upright posture, anatomic variability of vessels, valves, intra-abdominal pressure variations, and high body mass index. The deleterious effect of varicocele on spermatogenesis has been linked to influences on testicular functions including increased intra-scrotal temperature, venous reflux of toxic renal and adrenal metabolites, reduced oxygen tension, prostaglandins, and sperm cell apoptosis 7, 8.  Varicocele in athletes Physical exercise has a range of effects on the male hypothalamus-pituitary-gonadal (HPG) axis and fertility, depending both on the type, intensity and duration of the activity, and on the fitness and characteristics of the individual 9.  To date, evaluations of semen characteristics and fertility in athletes have been carried out mainly on healthy male individuals.  Most authors have not found any sports-related modifications of semen parameters or fertility.  Others have found reduced total sperm count and/or reduced normal sperm motility and morphology related to the volume of training and the number of kilometres run per week 10, 11.  Few studies have evaluated the impact of physical activity on the spermatogenesis or fertility of male athletes with andrological diseases (e.g. varicocele) 12.  This is probably due to the fact that in-depth andrological evaluations are not common during athletes’ pre-participation physical examinations (PPE).   Recent studies in athletes with varicocele showed that the percentage of spermatozoa with forward progression and normal morphology was significantly lower compared to non-athletes with the same degree of varicocele, whereas there was no decrease observed in the semen of healthy athletes 12.  Interestingly, a reduction of mean left testicular volume was observed in both athletes and non-athletes with varicocele, but mean left testis volume was significantly lower than the controlateral testis only in athletes with varicocele.  In addition, Rigano et al. 13 found a positive correlation between the number of adolescent athletes with varicocele and the highest grade of varicocele compared with the group of non-athlete adolescents.   Athletic participation might be an “aggravating factor” in the pathogenesis of the observed varicocele-linked sperm alterations. Furthermore, the literature indicates that physical activity negatively influences seminal fluid in healthy athletes with a high level of training, in athletes with varicocele a lower level of training might be able to favour testicular and/or sperm alterations.   In athletes with varicocele, exercise-related deleterious, systemic factors (altered gonadotropins secretion, increased antigonadic stress-dependent hormones: corticotropin-releasing hormone (CRH), cortisol, and opioids) may be also involved in the genesis of testicular and seminal alterations.  Several authors have shown that exercise-induced hormonal modifications of pituitary-testicular axis may result in alteration of both qualitative (pulsatile secretion and biological activity) and quantitative gonadotropin secretion 9, 14 and of testosterone production.  There have been no studies to evaluate the effects of exogenous anabolic androgenic steroid administration in male athletes on the reproductive system and/or fertility in relation to varicocele.  Detection of varicocele In many athletes, the discovery and diagnosis of an asymptomatic varicocele is detected during a clinical examination of the testicular vessels and gonads as part of the Official Journal of FIMS (International Federation of Sports Medicine)  142 Varicocele and sports participation  International SportMed Journal, Vol. 9 No.3, 2008, pp.141-144, http://www.ismj.com PPE.  As in the general population, a varicocele is also diagnosed during the evaluation of scrotal pain or fertility status.   The physical examination of the athlete’s scrotum and contents should be performed in both the recumbent and upright positions.  A palpable varicocele feels like a “bag of worms”, but can be significantly reduced in the recumbent position.  If a suspected varicocele is not clearly palpable in the supine position, the athlete should be examined in the standing position after a Valsalva manoeuvre.  The changes from supine to standing form the basis for the grading system of varicocele severity.  In athletes with a questionably palpable varicocele, the diagnosis can be confirmed by an ultrasound-Doppler examination of the testicular vessels.  Ultrasound examination can be also performed to evaluate testicular volume (testis volume = 0.525×a×b×c; where a, b, c are testis diameters), that is often reduced in the testis ipsilateral to the varicocele.  Clinical guidelines suggest that ancillary diagnostic measures (e.g. ultrasonography, spermatic venography, thermography, radionuclide scanning, and magnetic resonance angiography) should not be used for the detection of varicocele in athletes without a palpable varicocele.  However, ultrasonography may be indicated for clarification of an inconclusive physical examination of the gonads in infertile male athletes (e.g. sub-clinical varicocele).  Semen analysis (pH, viscosity, volume, sperm concentration, motility and morphology) and hormone evaluation (LH, FSH, prolactin, inhibin B, and testosterone) can be performed to further evaluate the clinical and seminal situation.   Varicocele treatment The efficacy of varicocele treatment is still in doubt 15, 16, and the therapy decision is particularly difficult in adolescents 17.  In men with varicocele and infertility and/or semen abnormality, both surgical ligation and percutaneous embolisation of the refluxing veins is still controversial 14, 19, and is clearly not recommended by some authors 20.  However, the reported need for early treatment of varicocele in the general population 21, 22, together with the possibility that physical activity may represent an aggravating factor for spermatogenesis 12 lends support to scheduled in-depth follow-ups of athletes with varicocele (e.g. evaluation of testis volume and/or of semen characteristics and/or hormone evaluation), and treatment guided by clinical status (e.g. infertility, abnormal semen parameters, reduced testis volume), particularly in younger athletes.  The treatment goal should be to preserve fertility status.  Varicocele, PPE and sport participation Managing varicocele in athletes is consistent with the main purposes of the PPE and includes (1) identifying athletes with varicocele whose sport activity may expose them to additional risks (e.g. exacerbation of the disease, testicular trauma.), (2) recognising those athletes who require treatment or clinical monitoring, and (3) counselling athletes who may benefit from a change to another type of exercise.  A genital exam during the PPE would permit the detection of a high percentage of athletes affected by varicocele.  The detection of a varicocele in athletes, while not limiting sports participation, would promote monitoring and/or treatment in athletes with infertility problems.  As in the general population 8, the treatment in adult athletes with palpable varicocele, currently attempting to conceive, is indicated in the case of abnormal semen parameters or sperm functions, if the female partner has normal fertility.  As with non-athletes, young athletes with varicocele with reduced ipsilateral testis size and/or abnormal semen analyses should be offered varicocele repair.  When sport might be seen as an “aggravating factor“in the pathogenesis of the varicocele-linked sperm alterations, athletes with varicocele and normal testis size and/or semen analyses should be offered follow-up monitoring of testicular size and/or semen analyses every six months to one year, depending on the athlete’s age, degree of varicocele, and the type of sport practiced (e.g. specific caution regarding sports where there is frequently increased abdominal pressure, etc.).   Conclusion There is a high prevalence of varicocele in the general population, but particularly in athletes.  As it represents the disease found Official Journal of FIMS (International Federation of Sports Medicine)  143 Varicocele and sports participation  International SportMed Journal, Vol. 9 No.3, 2008, pp.141-144, http://www.ismj.com most frequently in infertile men, an adequate follow-up and/or treatment is/are necessary according to individual clinical (e.g. pain, etc.) and functional status (e.g. seminal parameters, fertility, hormones).  Sports physicians should be aware of an early diagnosis and management of varicocele in athletes, and use the PPE as an opportunity to evaluate for varicocele and prevent infertility. 10. Arce JC, De Souza MJ. Exercise and male factor infertility. Sports Med 1993; 15:146-169.  11. Jensen CE, Wiswedel K, McLoughlin J, et al. Prospective study of hormonal and semen profiles in marathon runners. Fertil Steril 1995; 64: 1189-1196. 12. Di Luigi L, Gentile V, Pigozzi F, et al. Physical activity as a possible aggravating factor for athletes with varicocele: Impact on the semen profile. Hum Reprod 2001; 16: 1180-1184.  Address for correspondence: Professor Luigi Di Luigi, Unit of Endocrinology, Department of Health Sciences, University of Rome “Foro Italico”, Rome, Italy. 13. Rigano E, Santoro G, Impellizzeri P, et al.  Varicocele and sport in the adolescent age: Preliminary report on the effects of physical training. J Endocrinol Invest 2004; 27: 130-132. Email: luigi.diluigi@iusm.it 14. Di Luigi L, Guidetti L, Baldari C, et al. Physical stress and qualitative gonadotropin secretion: LH biological activity at rest and after exercise in trained and untrained men. Int. J Sports Med 2002; 23:307-312. References 1. Naughton CK, Nangia AK, Agarwal A. Pathophysiology of varicoceles in male infertility. Hum Reprod Update 2001; 7:473-481. 15. Evers JL, Collins JA.  Assessment of efficacy of varicocele repair for male subfertility: A systematic review. Lancet 2003; 361:1849-1852. 2. World Health Organization. The influence of varicocele on parameters of fertility in a large group of men presenting to infertility clinics. Fertil Steril 1992; 57: 1289-1293. 16. Marmar JL, Agarwal A, Prabakaran S, et al.  Reassessing the value of varicocelectomy as a treatment for male subfertility with a new meta-analysis. Fertil Steril 2007; 88: 639-648.  3. Di Luigi L., Romanelli F. Pigozzi F, et al.  Role of sport medicine in andrological prevention. Med Sport 1994; 47: 665-670. 4. Scaramuzza A, Tavana R, Marchi A. Varicoceles in young soccer players. Lancet 1996; 348:1180-1181. 17. Glassberg KI.  The adolescent varicocele: Current issues. Curr Urol Rep 2007; 8: 100-103. 5. Redmon JB, Carey P, Pryor JL. Varicocele: The most common cause of male factor infertility? Hum Reprod Update 2002; 8: 53-58. 18. Evers JL, Collins JA. Surgery or embolisation for varicocele in subfertile men. Cochrane Database Syst Rev. 2004; 3, CD000479. 6. Brugh VM 3rd, Matschke HM, Lipshultz LI. Male factor infertility. Endocrinol Metab Clin North Am 2003; 32: 689-707. 19. Ficarra V, Cerruto MA, Liguori G, et al. Treatment of varicocele in subfertile men: Cochrane Review--a contrary opinion. Eur Urol 2006; 49: 258-263. 7. Fretz PC, Sandlow JI. Varicocele: Current concepts in pathophysiology, diagnosis, and treatment. Urol Clin North Am 2002; 29: 921-937. 20. Kamischke A, Nieschlag E. Varicocele treatment in the light of evidence-based andrology. Hum Reprod Update 2001; 7: 65-69. 8. The Practice Committee of the American Society for Reproductive Medicine. Report on varicocele and infertility. Fertil Steril 2006; 86(Suppl 4):S93-S95.  21. Lenzi A, Gandini L, Bagolan P, et al. Sperm parameters after early left varicocele treatment. Fertil Steril 1998; 69: 347-349. 9. Hackney AC. The male reproductive system and endurance exercise. Med Sci Sports Exerc 1996; 28: 180-189. 22. Silber SJ. The varicocele dilemma. Hum Reprod Update 2001; 7: 70-77  Official Journal of FIMS (International Federation of Sports Medicine)  144 

Varicocele and sports participation

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Varicocele and sports participation

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