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1 대한요로생식기감염학회지 : 제 4 권제 2 호 2009년 10월 Korean J UTII Vol. 4, No. 2, October 2009 원저 정계정맥류환자에서농정액증의의의 국립경찰병원비뇨기과 이명진 조승훈 임종완 이승태 민승기 [Abstract] Significance of Pyospermia in the Patients with Varicocele Moung Jin Lee, Seung Hoon Cho, Jong Wan Lim, Seung Tae Lee, Seung Ki Min From the Departments of Urology, National Police Hospital, Seoul, Korea Purpose: Pain is one of the indications to treat varococele at any age. The purpose of this study is to find the significance of pyospermia in the patients surgically treated for scrotal pain associated with varicocele. Material and Methods: From January 2002 to December 2008, a total of 365 men underwent varicocelectomy. As the preoperative semen analysis, we classified patients of scrotal pain into two groups as pyospermia group I (N=136) and non-pyospermia group II (N=112). Preoperative and postoperative clinical symptoms were analyzed. The result was classified into completely resolved, partially resolved and unchanged based on the relief of pain. Results: Of 365 men, 248 (67.95%) patients were available for follow-up 3 months postoperatively. Among 119 patients with scrotal pain who have received the varicocelectomy, 42 (65.63%) and 5 (7.8%) patients in group I (64 patients) reported completely resolved and partially resolved respectively (mean response rate 73.44%). In group II (55 patients), 42 (76.36%) and 8 (14.55%) reported completely and partially resolved respectively (mean response rate 90.90%) (p<0.05). Seventeen and 5 patients in group I and II reported persistent pain, respectively. Conclusions: Patients with pyospermia surgically treated for scrotal pain associated with varicocele have tendency to have persistent pain after surgical treatment. This result may help the varicocele patients with persistent pain after receiving the surgery. (Korean J UTII 2009;4: ) Key Words: Varicocele, Pyospermia 교신저자 : 민승기, 국립경찰병원비뇨기과서울시송파구가락본동 58 번지우 Tel: , Fax: , msk0701@hanmail.net Received: September 7, 2009 / Accepted: September 28,
2 이명진외 : 정계정맥류환자에서농정액증의의의 197 서론정계정맥류는내정계정맥혈의역류로인해고환상부의만상정맥총이비정상적으로확장된질환이다. 성인남성의약 15% 에서발생하며남성불임환자의 35% 에서발견되는, 외과적치료가가능한가장흔한남성불임증의원인이다. 1 불임환자에서정계정맥류절제술후정액지표의호전이나임신율이증가될수있으므로 2,3 정계정맥류환자에서정액검사의가치는잘알려져있다. 정계정맥류환자에서술전시행한정액검사에서농정액증이발견되는경우가있으며대부분은큰의미를두지않고있다. 하지만농정액증은정자운동성의저하와관련하여불임과관련이있을것이라고추측된다. 또한전립선통환자에서농정액증을보이면염증성골반통증후군으로분류되어 4 전립선염을분류하는하나의진단기준이되고있다. 정계정맥류환자에서남성불임증을제외하고음낭상부에서촉지되는연성종물이나동통을주소로내원하는경우도많으며, 5 이러한동통성정계정맥류환자들의통증의양상은만성전립선염환자의통증과유사하다. 저자들은정계정맥류절제술전에시행한정액검사에서농정액증이발견된군과농정액증이없는군으로분류하고수술전후의임상양상을비교하여정계정맥류환자에서농정액증의의미를알아보고자하였다. 대상및방법 2002년 1월부터 2008년 12월까지본원에서정계정맥류절제술을시행받은환자 365명중치료 12 주후에추적관찰이가능했던 248명을대상으로하였다. 모든환자는신체검사와음낭색도플러초음파검사를시행하였으며, 신체검사에서음낭종물이있는경우, 음낭색도플러초음파검사를시행하여만상정맥총의혈관직경이 3mm 이상이거나정맥혈의역류가있는경우정계정맥류로확진하였다. 정계정맥류의정도는 Dubin과 Amelar의방법 6 에따라 grade I부터 III까지로구분하였다. 모든환자에대하여수술전정액검사를시행하였으며, 400배고배율에서백혈구수치가 10개이상인경우농정액증이라고정의하였다. 수술은 2명의숙련된술자에의해행해졌으며, 수술방법은 242명에서복강경정계정맥류절제술이시행되었으며, 나머지 6명에서서혜부하정계정맥류절제술이시행되었다. 술후 12주째신체검사나음낭도플러초음파검사를시행하여재발이나합병증에관하여평가하였다. 신체검사와음낭색도플러초음파검사에서재발이없으나증상이소실되지않은경우는술후 6개월까지외래추적관찰하였다. 술후 12주째추적관찰이가능했던 248명중수술전정액검사에서농정액증이발견된환자를 Group I, 농정액증이없는환자를 Group II로분류하여수술을받게된동기, 정계정맥류의정도, 술후 12주째동통의소실에대하여후향적으로비교분석하였다. 술후동통의소실에대한평가는환자들의주관적증상을바탕으로 완전소실, 부분소실, 동통지속 의 3가지로나누었다. 완전소실은행동의제약없이일상생활을하여도동통이없고진통제의사용이필요하지않은경우로정의하였다. 부분소실은약간의불편감이있고일상생활은가능하나약간의제약을받는경우로진통제의사용은본인이원하는경우로정의했으며, 동통지속은술전과비교시동통의변화가없거나더심해지는경우로정의하였다. 통계분석은 Student`s t-test와 chi-square test를이용하였고 p 값이 0.05 미만이면통계적으로의미있는것으로간주하였다. 통계프로그램은 SPSS 13.0 을사용하였다. 결과술전시행한정액검사에서농정액증이발견된환자군 (Group I) 은 136명이었고, 농정액증이없는환자군 (Group II) 은 112명이었다. Group I 및 II의평균연령은각각 23.32±5.94세및 24.88±7.22세로대부분 20대의건강한미혼남성이었다 (p<0.05). 술전정액검사에서정자농도와운동성중어느한
3 198 대한요로생식기감염학회지 : 제 4 권제 2 호 2009 년 10 월 Table 1. Characteristics of varicocele patients Pyospermia (n=136) Non-pyospermia (n=112) p-value Mean age (years) 23.32± ± * Abnomal preoperative semen analysis 18 (13.23%) 13 (11.60%) Chief complaint Scrotal mass 72 (52.94%) 57 (50.89%) Scrotal pain 64 (47.06%) 55 (49.11%) Grade Ⅰ 32 (23.52%) 23 (20.54%) Ⅱ 44 (32.35%) 34 (30.36%) Ⅲ 60 (44.12%) 55 (49.11%) *: Student`s t-test, : chi-spuare test Table 2. Pain subside at 3 months after operation (n=119) Response Pyospermia (n=64) Non-pyospermia (n=55) p-value Complete subside (%) 42 (65.63) 42 (76.36) Partial subside (%) 5 (7.81) 8 (14.55) 0.037* No subside (%) 17 (26.56) 5 (9.09) *: chi-square test 가지라도이상을보인증례는 Group I에서 18명, Goup II에서 13명이었다. 양군에서수술방법은 Group I에서 4명, Group II에서 2명이개복을통한서혜부결찰술을시행하였으며, 나머지는복강경정계정맥류절제술을시행하였다. 양군에서수술을받게된동기는 Group I에서고환종괴가 72명 (52.94%), 음낭동통이 64명 (47.06%), Group II에서고환종괴가 57명 (50.89%), 음낭동통이 55명 (49.11%) 으로통계적으로유의한차이를보이지않았다 (p>0.05). 두군에서정계정맥류의정도는 Group I에서 Grade I, II, III가각각 32명 (23.52%), 44명 (32.35%), 60명 (44.12%), Group II에서 Grade I, II, III가각각 23명 (20.54%), 34명 (30.36%), 55명 (49.11%) 으로통계적으로유의한차이를보이지않았다 (p>0.05) (Table 1). 두군에서음낭동통을주소로수술을시행한 119명의수술 12주후수술치료의결과는 Group I에서 64명의환자중 42명 (65.63%) 이통증의완전소실, 5명 (7.8%) 이부분소실로 73.44% 가반응을보였다. 그반면 Group II 에서 55명의환자중 42명 (76.36%) 이통증의완전소실, 8명 (14.55%) 이부분소실로 90.90% 가반응을보여두군에서통계적으로유의한차이가있었다 (p<0.05) (Table 2). Group I과 II가각각 17명, 5 명에서음낭동통의증상이지속되었으며이들에서수술후 6개월까지추적관찰결과항생제 ( 퀴놀론계 ) 치료후각각 15명, 2명이통증의감소를보였다 (Fig. 1). 고찰정계정맥류는교정가능한남성불임의가장흔한원인으로받아들여지고있으며 7 정계정맥류절제술을통한가임력회복이나정액지표의호전에관해서는많은연구가이루어져왔다 하지만미혼남성의경우는대부분음낭종물이나통증을주소로내원하게되며이러한통증을동반한정계정맥류의치료와정계정맥류절제술의효과에대한연구는부족하다. 통증을동반하는빈도는 2~10% 정
4 이명진외 : 정계정맥류환자에서농정액증의의의 199 % Pain(-) Pyospermia 62 Pain(+) Non-pyospermia M 6M 3M 6M Fig. 1. The varicocele patients with pyospermia had tendency to have persistent pain 3months after the surgery. Pyospermia group reported persistent pain after using antibiotics (quinolone) for 3months, showed more effect about resolved pain than non-pyospermia group. 도로추정하고있으며활동이높은젊은층에많은것으로보고되고있다. 5 저자들의경우통증을주소로내원한정계정맥류환자는 47.98% (119/248 명 ) 으로높은빈도를보였고그평균연령이 세로 20대가대부분이었다. 이는저자들의병원특성상환자대부분이병역의무를이행중인전 의경으로서신체활동이많으며통증이있는경우대부분수술적치료를선호하였기때문이라생각한다. 이러한조건은한편으로전체정계정맥류환자에대한분석을어렵게할수도있지만동통을주소로내원한정계정맥류환자에대한연구로는적합할것으로생각한다. 현재까지정계정맥류환자의통증의원인은망상총에서발생하는정맥성의울혈때문이며, 복압의증가시이정맥성의울혈이악화되어통증혹 은불쾌감이더심해지는것으로알려져있다. 이음낭의통증은예리하거나방사되지않는일정한압력성및박동성의고환둔통이특징이며, 서있을때악화되나누울경우에는호전된다. 치료로는정계정맥류의정도가심하지않거나정액검사를시행하여별이상이없는경우, 음낭거상이나진통소염제, 안정, 활동제한등보존적치료를시도하기도하지만현재는앞에서언급한임신율에대한효과나정액지표의개선효과로인하여대부분의경우수술이이루어지고있다. 정계정맥류의수술적치료법은후복막접근법, 서혜부혹은서혜부하접근법과같은절개수술법, 복강경수술법, 경정맥색전술및미세수술기법의서혜부하절개술이있으며, 수술후보통 2 3개월째신체검사나음낭도플러초음파검사를통하여재발이나합병증의여부를판단하게된다. 동통을주소로내원한정계정맥류환자에대한동통의소실에대한효용성은 Ryu 등 13 이 88.4% 에서, Kim 등 14 은 88.3% 에서효과가있다고발표하였다. 저자들의경우역시 81.51% (97/119명) 에서동통의소실에효과가있었다. 저자들은수술후 3 6개월까지추적관찰하였으며 3개월째동통이지속되는경우초음파를시행하여재발여부를확인하였다. 수술후정계정맥류의재발은없으면서통증이지속되는환자들이 18.49% (22/119명) 를차지하였다. 음낭통증은다른원인으로인하여발생하는만성생식기통증과감별되어야하며 15,16 특히만성전립선염이나요도염등의감염, 종양, 서혜부탈장교정술등의과거의수술및연관통등을배제해야한다. 만성전립선염의새로운분류에서는전립선통환자에서농정액증을보이면기존의전립선통환자가염증성골반통증후군이된다. 4 농정액증이만성전립선염을진단하는하나의기준이되고있다. 농정액증은정액에서비정상적으로백혈구가존재하는것을말한다. 진단은예전에는고배율 (x400) 에서백혈구수치가 10 이상인경우농정액증이라하였으나현재는정액에서백혈구수가 /ml개이상이거나혹은 100개의정자를헤아렸을때 6개이상인경우로하고있다
5 200 대한요로생식기감염학회지 : 제 4 권제 2 호 2009 년 10 월 농정액증은세균에의한정세관상피의손상이나부고환폐쇄및세균의정자에대한직접부착등이남성불임의원인으로받아들여져왔으나, 백혈구나백혈구에서분비되는물질에의해서도생식력이저하되고, 백혈구가제외된백혈구가분비된물질만으로도정자의운동성이저하됨이보고되었다 대부분의농정액증의연구가남성의불임과관련되어연구가진행되고있으나회음부나고환의통증을가지고있는농정액증에대해서는전립선의염증이나정액낭의염증을고려해야한다고보고하고있다. 23 정계정맥류가있는환자에서수술전정액검사는임신율이나정액지표를평가하기위해모든환자에대하여시행하고있다. 하지만농정액증이있는경우대부분의의사들이특별한의미를두지않고있는것이사실이다. 저자들은농정액증이만성전립선염의진단에중요한역할을하며만성전립선염도정계정맥류의통증과비슷한양상의통증을일으킬수있다는것에주목하였고, 정계정맥류환자중농정액증이있는군과농정액증이없는군에서통증의양상을분석하여음낭의통증이만성전립선염이원인일수도있다는사실을발견하였다. 또한대상의수가작아서통계적유의성은알수없으나 3개월까지통증이지속된군에서만성전립선염에준하는치료를하여농정액증이없는군에서보다농정액증이있는군에서좋은결과를거두었다. 앞으로더많은대상에연구가진행되어야하겠지만, 농정액증이있으면서정계정맥류수술을시행하여증상의소실이없는환자에대하여항생제의기간이나종류를만성전립선염에준하여치료할경우좋은결과를거둘수있을것으로생각한다. 결론정계정맥류환자에서농정액증이발견된군은농정액증이없는군과비교하여수술을받게된동기나정계정맥류의정도에는유의한차이를보이지않았으나, 음낭동통을주소로수술을시행한환자의수술 12주후수술적치료의결과는농정액 증이있는동통성정계정맥류군에서는수술후동통이지속되는경우가많았다. 이러한원인은농정액증을가진정계정맥류환자의통증이정계정맥류에의한증상뿐아니라염증성만성골반증후군과관련되어있기때문일것으로추측된다. 이러한결과는동통성정계정맥류환자에서수술후동통의소실이없는환자의치료에도움이될수있을것으로생각한다. REFERENCES 1. Mark JL, McMahon R, Lipshultz LI. Predictive parameters of successful varicocele repair. J Urol 1986; 136: Pryor JL, Howards SS. Varicocele. Urol Clin North Am 1987;14: Syndel AW, Yan Y, Naughton CK. Dose the number and size of vein ligated at outcomes? Urology 2007; 69: Krieger JN, Nyberg L Jr, Nickel JC. NIH consensus definitionand classification of prostatitis. JAMA 1999;282: Peterson AC, Lance RS, Ruiz HE. Outcomes of varicocele ligation done for pain. J Urol 1998;159: Dubin L, Amelar RD. Varicocelectomy: 986 cases in a twelve year study. Urology 1977;10: Lipshultz LI, Thomas AJ Jr, Khera M. Surgical management of male infertility. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh urology. 9th ed. Philadelphia: Saunders; 2007; Marmar JL, Agarwal A, Prabakaran S, Agarwal R, Short RA, Benoff S, et al. Reassessing the value of varicocelectomy as a treatment for male subfertility with a new meta-analysis. Fertil Steril 2007;88: Agarwal A, Deepinder F, Cocuzza M, Agarwal R, Short RA, Sabanegh E, et al. Efficacy of varicocelectomy in improving semen parameters: new meta-analytical approach. Urology 2007;70: Edward CS, Steven JH, Mark LF, Larry IL, Edward DK. Varicocelectomy improves sperm strict morphol-
6 이명진외 : 정계정맥류환자에서농정액증의의의 201 ogy and motility. J Urol 1998;160: Choi WS, Kim TB, Paick JS, Kim SW. Factors related to improvement or normalization of semen parameters after microsurgical subinguinal varicocelectomy. Korean J Urol 2009;50: Shin JW, Kim SW, Paick JS. Effects of varicocele treatments in adolescents: changes of semen parameters after early varicocelectomy. Korean J Urol 2005; 46: Ryu DS, Chong CH, Oh TH. The Effectiveness of varicocelectomy in patients with painful varicocele. Korean J Urol 2001;42; Kim JS, Min SK, Jo MK. Effect of varicocele ligation for patients with painful varicocele. Korean J Urol 2001;42: Kursh ED, Schover LR, The dilemma of chronic genital pain. In: Thomas P, Novicki DE, Barrett DM, Devine CJ, Donohue JP, Duckett JW, et al. editors. AUA Update Series 1997;18: Hayden LJ. Chronic testicular pain. Aust Fam Physician 1993;22: Sigman M, Lopes L. The correlation between round cells and white blood cells in the semen. J Urol 1993;149: Shy KK, Stenchever MA, Muller CH. Sperm penetration assay and subsequent pregnancy: a prospective study of 74 infertile men. Obstet Gynecol 1988;71: Would Health Organization. WHO semen manual for the examination of human semen and cervical mucus. Cambridge: Cambridge university press; 1992; Witkin SS, Jeremias J, Grifo JA, Ledger WJ. Detection of chlamydia treachomatis in semen by the polymerase chain reaction in male menbers of infertile couples. Am J Obstet Gynecol 1993;168: Barrett CL, Bolton AE, Cooke ID. Functional significance of white blood cells in the male and female reproductive tract. Human Reprod 1990;5: Soldati G, Piffaretti-Yenez A, Campane A, Marchini M, Luerti M, Baloma M. Effect of peritoneal fluid on sperm motility and velocity distribution using objective measurements. Fertil Steril 1989;52: Pentyala S, Lee J, Annam S, Alvarez J, Veerraju A, Yadlapalli N, et. al. SA. Current perspectives on pyospermia: a review. Asian J Androl 2007;9:
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