Management of Adolescent Variocele

 

By Hossein Aliabadi, M.D., F.A.A.P., F.A.C.S.

 


Table 1
Varicocele Ligation Indications

Symptomatic / large

Abnormal semen analysis

Testis size difference > 2.5 cc

Abnormal GN-RH infusion test

Testis growth retardation

Poor follow-up / compliance

 

 

 


Table 2
Varicocele Clinical Descriptions

Grade I

Small, palpable w/ difficulty

  9.4%

Grade II

Moderate, palpable

  3.6%

Grade III

Large, visible

  1.7%

 

   % of all adolescent males

 

 

 


Table 3
Varicocele Treatment Options

Observation

High ligation: Retroperitoneal Inguinal / Subinguinal / Microsurgical Laparoscopic clipping

Radiographic transverse occlusion

 

 

 


Table 4
Varicocele Ligation Complications
(<2 percent)

Hydrocele formation

Recurrence Persistence

Contralateral occurrence

 

 

   A varicocele is defined as an abnormal dilation of the veins of the pampiniform plexus of the spermatic cord caused by incompetent valves within the veins. When sufficiently dilated, the varicocele is easily diagnosed upon inspection. Approximately 15 percent of males develop a varicocele, with the incidence of detection gradually increasing between 10 and 15 years of age. While the overwhelming majority occur on the left side (> 90 percent), bilateral palpable varicocele are seen in less than 2 percent of the cases. Isolated right-sided varicocele are distinctly rare. Even though many theories have been proposed to explain the etiology of a varicocele, no single cause has been identified, and most likely, multiple factors together are responsible for its manifestation.1"4

The clinical significance of a varicocele is the potential for testicular injury, varying in severity and time of onset from azoospermia to no change in semen quality. It is this variation in extent of injury to testicular growth, function, and histology that has precluded consensus as to the indications for varicocele repair in adolescence. A majority of pediatric urologists, however, agree that varicocele ligation is indicated for older teenagers with demonstrable secondary effect on the testis, since in this setting there is evidence that the varicocele is responsible for impairment of testicular function (Table I).1 Physical examination in upright and supine positions remains the key to proper diagnosis of a varicocele.

In the standing upright position, the veins engorge and the varicocele may be palpable or even visible. With small varicoceles, a Valsalva maneuver may make them more prominent. With the child in the supine position and the scrotum elevated, the varicocele should collapse and become less prominent. Occasionally, color Doppler ultrasound may be used to diagnose a sub-clinical varicocele, however there is presently no evidence that sub-clinical varicoceles have any importance in the adolescent age group.' Therefore, we do not recommend Doppler ultrasonography for routine use in this age group. The majority of varicoceles in our practice are discovered during routine physical examination by the primary care physician and are subsequently referred to us for follow up evaluation.

      Depending on its size, the varicocele is described in grades I, II and III (Table 2). While the relationship between the grade of the varicocele and the effects on fertility is unclear, there is a direct correlation with the volume of the left testis.  It appears that grade I varicocele does not result in significant change in testicular volume.1 In about 30 percent of boys with a grade n left varicocele, there is measurable difference in the size of the testis. This figure approaches 80 percent in boys with grade III varicocele.

Histologic correlation reveals observable abnormalities in human testis biopsy material. While typically more pronounced on the left, the right testis eventually becomes involved. The abnormalities recognized include tubular thickening, decreased spermatogenesis, and maturation arrest. Presence of Leydig cell hyperplasia indicates a very poor prognosis for fertility, whereas atrophy signifies less severe outcomes.2'3'3 Analysis of semen specimens appear to show a decrease in the normal sperm forms in the ejaculate and in sperm motility in young males with a varicocele. In our assessment, however, semen analysis should not be routinely used in adolescent boys. Testicular biopsy is also not recommended.

Evaluation of hormonal responses before and after correction of varicoceles in young men suggests that varicoceles can also induce abnormalities in hormone synthesis, as well as tesricular dysfunction. This observation has led to the development of the gonadotropin-releasing hormone (GN-RH) stimulation test to help identify tesricular dysfunction associated with a varicocele in selected individuals. We recommend selective surgical intervention for older teenagers with evidence of testicular impairment who may be at increased risk for infertility in the future. While there is evidence for partial reversal of testicular growth retardation following ligation of grade II and HI varicoceles, there does not seem to be any evidence to support prophylactic varicocele ligation in this age group. Instead, annual examination with determination of testicular volume, consistency, grade of varicocele, and presence or absence of symptoms would be recommended.

     Varicocelectomy is the most commonly performed operation for the treatment of male infertility, and a variety of approaches are described. While inguinal varicocelectomy is currently the most popular approach (Figure 1), we prefer the retroperitoneal technique (as described by Palomo) or laparoscopic varicocelectomy (Table 3).  Both options have provided us with excellent results in the adolescent age group without testicular atrophy, reactive hydrocele, or recurrence of ipsilateral varicocele. This is further supported by reports in the literature illustrating lowest complication or recurrence rates utilizing the retroperitoneal technique.1'2

    While we have been exposed to the radiographic occlusion techniques of the past, including intraoperative venograms to help reduce the incidence of varicocele recurrence, we have found this approach lacking in utility with the adolescent age group, coupled with the high radiation dosages necessary and a high recurrence rate which ultimately requires a surgical approach,6 and therefore we do not recommend them. Complications have been distinctly uncommon and are confined to hydrocele, recurrence of the varicocele, manifestation of a contralateral varicocele, and short-term, limited orchialgia (testicular pain) (Table 4).

CONCLUSION

     Varicoceles are common anomalies in adolescent boys that can potentially result in testicular injury, including hormonal, histologic, and fertility abnormalities.  Currently, no single modality can predict chances for infertility in the adolescent with a varicocele. However, when surgery is indicated, the participation of a pediatric urologist who can help define the problem and provide surgical repair may help avoid irreversible infertility in a proportion of these patients.

REFERENCES

1. Kass EJ, Belman AB. Reversal of testicular growth failure by varicocele ligation. / Uml 1987; 137: 475-6.

2. Kass EJ, Reitelman C. Adolescent varicocele. Llrol din N Amer 1995;

3. Bickel A, Dickstein G. Factors predicting the outcome of varicocele repair
for subfertility. / Urn! 1989;142:1230-4.

4. Skoog SJ, et al. The adolescent varicocele: What's new with an old problem in young patients. ftdratrio;100(l):112-22.

5. Atassi O, Kass EJ, Steinert BW. Testicular growth following successful varicocele correction in adolescents: Comparison of artery sparing techniques with the Palomo procedure. / Uml 1955;482-3.

6. Zaonotz MR, Firlit CF. Use of venography as an aid in varicocelectomy. J Ural 1987;138:1041-2.

 

 

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