男性不育之精索静脉曲张治疗

发布时间:2016-05-04 11:47:19 阅读量:23,367

精索静脉曲张很常见,发病率为生育期男性人群的10%~15%,在男性不育中占30%左右。可以引起少精、弱精、畸形精子增多、死精子增多等各种各样的精子质量问题。因为特别多见,我把它单列出来,稍微强调一下。

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精索静脉曲张95%发生在左侧的精索,对精子生成机制的影响,主要是与曲张后的睾丸局部温度增高、血液循环障碍并影响营养和血氧的供应,静脉血液逆流、干扰睾丸间质的内分泌功能等,影响精子的产生过程。

病人一般会有间断性的阴囊、左下腹等部位坠胀不适的感觉,尤其是在有性兴奋而没有得到释放的情况下,特别明显,在劳累、长时间的行走、剧烈运动后症状也会加重,而在平卧、休息后可以缓解。

这个病通过临床检查、病史、彩超或者B超检查,基本可以诊断,如果有必要,可以进行精索静脉造影,这是目前诊断精索静脉曲张最可靠的方法。

精索静脉曲张的治疗,是要按照症状的轻中重以及是否伴有不育来处理的。

没有症状的轻度曲张一般不需治疗。

如果仅有轻微的不适,可采取提睾带、阴囊托、冷敷的方式;进行支持治疗,性活动中不要忍精不射;

这个病轻微的对少精弱精影响不大,影响较大的曲张,手术治疗、介入治疗是比较理想的方式。药物治疗的效果很不理想,不要乱花冤枉钱、不要浪费时间。

大家注意一下手术治疗和介入治疗的适应征:

如果具有中度的不适,但同时伴有较为严重的少精弱精不育患者;或者临床症状较重疼痛剧烈的;或者有睾丸萎缩的;这是手术和介入治疗的指征。

手术一般采用精索内静脉高位结扎。腹股沟上方2~3公分的小切口,把肿胀的静脉血管结扎就可以了,都说阑尾炎是腹部外科最简单的手术,这个手术比阑尾炎简单得多,也安全得多。但存在术后复发和术后鞘膜积液的问题。

近年来兴起的显微外科精索静脉曲张切除术,从报道上看,似乎并发症及复发率大为降低。

除非有双侧精索静脉曲张,或者以前曾经进行过手术又复发的病患,才可以考虑用腹腔镜手术来治疗。

腹腔镜的滥用不可行,主要是因为有不少医生不遵守手术的适应症,盲目扩大治疗范围。一些医疗机构,以为购买了比较贵的仪器,什么病都靠它来解决,这是严重错误的。使用不使用,要看临床适应征,单侧的手术,治疗就那么2公分的切口,是在眼睛直视下,用灵巧的双手来手术,而腹腔镜仍然需要在腹部2、3个小切口,加起来比手术的切口还大,还要复杂的操作,能看到是通过屏幕转播的平面,不是立体的,操作不是灵巧的双手,而是通过机械臂来完成,手术时间,人家10分钟就结束了,腹腔镜40分钟一个小时还在那里忙活,高位结扎的手术,花费总共才千把块钱,一个腹腔镜万把块钱,这种腹腔镜优势,只有某些机构的敛财优势。

精索静脉曲张的介入治疗,就更简单了,是通过导管选择性的向精索内静脉注入栓塞物比如明胶海绵、弹簧钢丝或硬化剂等以达到闭塞曲张静脉的目的。介入治疗不手术、费用也少、痛苦也小,也可以避免阴囊水肿、血肿等手术并发症,也是可以采取的。

精索静脉曲张不育症者,手术后或介入治疗后精液改善率可达50%~80%以上,具体成功怀孕的效果,还要看术前患者的精子数目,有文献统计,术前精子数目大于1000万/毫升,术后精液改善率为85%,妊娠率可达70%;术前精子数目小于1000万/毫升,精液改善率仅为35%,妊娠率仅27%。如果是无精子症伴有精索静脉曲张,除非疼痛明显,否则不推荐手术治疗,因为经过手术治疗后恢复生育能力的可能性仍然微乎其微。

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