Varicocele in Children and Adolescents

Background

• Varicocele is a vascular lesion characterized by tortuous dilatation of the spermatic veins in the scrotum. It is sometimes described as having a "bag of worms" appearance or consistency.
• Though surgery is often not indicated for the condition, varicocele is the most common surgically correctable urologic abnormality in male adolescents.
• The prevalence of varicocele is about 8%-20%, beginning with testicular growth at puberty, but the true prevalence may be higher since most adolescent varicoceles are asymptomatic and are discovered incidentally during a routine physical exam.
• Varicoceles are typically unilateral on the left; they can be either primary from venous pathology (the more prevalent subtype in this age group) or secondary from increased pressure on spermatic veins.
• Potential complications of an untreated varicocele include pain or discomfort, testicular hypotrophy or atrophy, low sperm count, hypogonadism, and risk of future infertility/subfertility as an adult. There is no evidence that varicocele repair as a child or adolescent offers better andrologic outcomes than repair that is performed in adulthood.

Evaluation

• Varicocele commonly appears during testicular growth in early puberty, with a notable spike in clinical presentation at about age 13 years.
• While most varicoceles are asymptomatic, 5%-10% of cases present with a dull ache or heaviness in the inguinal area or scrotum.
• Perform a physical exam in both the supine and standing positions, both without and with the Valsalva maneuver.
• Check for scrotal swelling and dilated veins (may be only noted when standing and absent in the supine position), palpate testes, and evaluate the testicular volume, size differential, and consistency.
• Base the diagnosis of a varicocele on a physical examination.
• Findings of dilated and tortuous gonadal veins by palpation or visual exam are diagnostic for clinical varicocele, and are used to assign clinical grades:
  • grade I - small varicocele (palpable only during Valsalva maneuver when standing)
  • grade II - moderate-size varicocele (readily palpable without Valsalva maneuver, but not visible when standing)
  • grade III - large varicocele (readily visible when standing)
• Detection of venous reflux into the plexus pampiniformis by color Doppler ultrasound is also diagnostic for varicocele. It is employed far less often than physical exam findings but can be an incidental finding when a scrotal ultrasound is performed for other indications.
• Consider imaging with a scrotal ultrasound to clarify or to confirm venous reflux when a physical exam is inconclusive or equivocal; an ultrasound can also be used for an objective estimation of the testicular volume.
• Perform a renal ultrasound to exclude a retroperitoneal mass:
  • in prepubertal children with a varicocele (Strong recommendation)
  • if isolated right varicocele (Strong recommendation)
  • in varicoceles that do not decompress in the supine position

Management

• The primary goals of treatment include preventing, minimizing, or reversing testicular insult, enhancing the growth of hypoplastic ipsilateral testis, preventing or reversing sperm production abnormalities, and, rarely, restoring normal hormone levels.
• Conservative management is usually indicated for asymptomatic patients without significant ipsilateral testicular hypotrophy. Monitor with annual exams through adolescence, or until a reliable semen analysis can be performed.
• Repair of varicocele in children and adolescents is controversial.
  • Indications for varicocele repair may include:
    • symptomatic varicocele (painful scrotum)
    • varicocele associated with significant difference in testicular volume with ipsilateral hypoplasia (difference of > 2 mL or 20% compared to right testis)
    • pathological sperm quality in older adolescents, although no agreed-upon standards for normal semen parameters in adolescents exist
    • presence of an additional testicular condition affecting fertility (such as, history of testicular torsion)
    • presence of bilateral palpable varicocele
  • When repair is indicated, there is no definitive evidence or consensus about the best procedure to use in terms of clinical outcome, lowest complication rate, and best cost/benefit ratio.
  • Major options for varicocele repair are surgery (varicocelectomy or varicocele ligation) or percutaneous occlusion/embolization.