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Urology
Adolescent Varicocele
What Patients and Parents Should Know
Varicocele can be defined as varicose veins of the testicle. Varicoceles in the adolescent are usually found on routine school or camp examinations and are totally without symptoms. On occasion there can be heaviness in the scrotum, but rarely is there any testicular pain.
The incidence of varicocele in the adolescent population is about 15 percent worldwide. A varicocele is associated with a time dependent growth arrest of the affected testis in adolescent and adult males. There is a clear association between varicocele, testicular growth retardation and infertility. It is well known that repair of a varicocele can reverse the growth arrest of the testis in adolescent boys.
It is known that not all varicoceles effect fertility potential. Since adolescents do not present with infertility issues, two questions about surgical correction need to be addressed.
- Should prophylactic repair be performed to protect fertility potential in the future?
- What should be the timing of repair. Is it better to do a varicocele repair in an adolescent with growth retardation or wait until a semen analysis might document fertility impairment?
In the general population of healthy males, the overall incidence of varicocele is between 10 and 15 percent. Of males presenting with primary infertility, somewhere between 30 and 50 percent will have a varicocele. Varicoceles present almost always on the left side, and they usually appear early in puberty. Occasionally they can be found in preadolescent boys and, not infrequently, bilaterally. Anatomy
Most investigators believe that varicoceles occur on the left side because the venous drainage from the left testis and spermatic cord is directly into the left renal vein as opposed to into the inferior vena cava on the right side. This direct drainage is a straight south-to-north conduit that can be adversely affected by increased hydrostatic pressure and valvular abnormalities of the veins. Pathophysiology
There are a number of theories that have been proposed in an attempt to explain the adverse effect of a varicocele on the associated testis. The most common and widely held theory is that regarding scrotal temperature. The presence of a varicocele is associated with elevated scrotal and testicular temperature, which in turn alters spermatogenesis. There are other potential theories for abnormal testicular function associated with varicocele. However, the finding of improvement of both testicular size and testicular function when the varicocele is interrupted lends credence to the hypothermia concept. Diagnosis
Varicoceles are most often asymptomatic. The individual should be examined standing up and the varicocele graded from Grade I, being the smallest, to Grade III, being the largest. Grade III varicoceles can be seen without the need for palpation. The second important aspect of the physical examination is to measure both testes. A testis which has been adversely affected by a varicocele will be smaller than its contralateral mate. Volume measurements obtained by ultrasound or with an orchidometer are reliable parameters for monitoring growth. Management
Once a varicocele has been found a decision on management should be made. Adolescents with growth retardation and a large varicocele are most often considered candidates for surgical intervention. There are a number of approaches that have been recommended, including open surgery, laparoscopic surgery and embolization. Summary
- Varicocele is associated with time dependent testicular growth arrest.
- Varicocele is the most common correctable cause of male infertility.
- In adolescent males, varicocele is usually asymptomatic, found on the left side, and diagnosed during routine physical examination.
- A greater than 15 to 20% volume differential between the two testicles, the left smaller than the right, is the best indicator of testicular damage and is often used as an indication for surgical repair in the adolescent varicocele.
- Varicocele repair can reverse growth arrest in the adolescent and may protect fertility potential in the future.
- Other tools for evaluating varicoceles include velocity measurements of retrograde flow, a measurement that can be obtained by Doppler at the time of ultrasound exam.
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