The Teenager with a Varicocele

A variococele is an abnormal enlargement of the veins of the testicle that usually produces no symptoms. The majority of teenagers with a varicocele are identified during a routine physical examination which demonstrates a nontender enlargment of the veins of the testicle.

A varicocele is the most common cause of infertility in adult men. Recently, interest has focused upon the adolescent with a varicocele because (1) a varicocele first develops early in adolescence, (2) the effect of a varicocele upon the testis may increase as the individual gets older, and (3) return of normal fertility following varicocele correction in infertile adult men is only possible in less than 50% of cases. Recent data would suggest that in some adolescent males, a varicocele has a significant effect upon testicular growth and function, and in these individuals, early treatment is preferred because if one waits too long, the process may not be reversible. However, in other individuals, the effect of the varicocele may not be so pronounced, and in these circumstances, careful observation and close follow up is recommended.

Anatomy
A varicocele most commonly involves the left testicle, but it can also, occassionaly, involve the right testicle. Blood from the testicle normally drains into a vein near the kidney. When a varicocele is present, there is a backward flow of blood from veins near the kidney into the veins of the testicle. The most common cause for a varicocele is defective valves within the testicular vein allowing reversal of the normal blood flow.

Incidence
Typically, a varicocele is first detected during early adolescence, and once present, it does not go away without treatment. In a studey of more than 4,000 school boys, a varicocele was not detected in boys less than 10 years of age, but the incidence of varicocele detection gradually increased between 10 and 15 years of age. After 15 years of age, the incidence of varicocele remained constant and varicoceles were not observed to disappear spontaneously or develop later in life.

Testicular Changes
Lipshultz and co-workers carefully measured testicular size in adult men with a varicocele and compared them with aged matched control groups without a varicocele. In individuals with a varicocele, the left tests was often smaller and frequently the right testicle was also significantly smaller.

Lyon and co-workers also noted a smaller left testis in 77% of 30 adolescent boys with a left-side varicocele. These investigators suggested that a varicocele may have a damaging effect on the rapidly growing testis in adolescents.

Kass and Belman surgically corrected the varicocele in a group of adolescent males with a left-sided varicocele and a smaller left testis. All of these boys (average age 13.8 years) had their varicocele discovered during a routine physical examination. A significant increase in size of the left testis was noted in 80% of patients following varicocele surgery, and in most cases, the size of both testes became equal in size.

These studies suggest that a varicocele can be responsible for impaired testicular growth and that early surgical correction of the varicocele in this circumstance may reverse this process.

Although a varicocele usually occurs on the left side, abnormailities in the adult can often be detected in both testes. Charney performed testicular biopsies in 36 infertile adult males with a varicocele and when the tissue was examined under the microscope, abnormalities were found in both testes. McFadden and Mehan performed testis biopsies on 101 infertile males with varicocele, and also noted abnormalities in both testes. Typically, the abnormality was more pronounced in the left testis, but the right testis was always involved.

Microscopic abnormalities have been observed in the testis of adolescents with a varicocele and they are similar to those found in adults, but generally not as severe. Hienz and co-workers performed testicular biopsies in 10 boys undergoing varicocele surgery and demonstrated microscopic testicular abnormalities in both testes. Kass and co-workers also demonstrated microscopic abnormalities in the testes of adolescents with a varicocele, but they were much less severe than those seen in adults.

Conclusions and Recommendations
At present time, there is good evidence that a varicocele is capable of producing a testicular injury in teenagers. The exact cause of the injury is unknown, however, the best theory is that a varicocele involving one testicle can cause an increase in the temperature in both testes. The effect of this temperature increase upon the testis will vary from person to person since not all men with a varicocele will become infertile. However, if is thought that with increasing age, the number of men that develop fertility problems will increase. Therefore, it is important to follow all individuals with a varicocele because it is not possible to predict when fertility problems will develop. It is likely that if an individual with a varicocel delays starting a family, he may have a greater chance for infertility than an individual who has his family at a younger age.

The question of reversibility of the testicular injury following varicocele surgery is difficult to answer. There is evidence to suggest that the potential for reversal or stabilization of the testicular injury is better with early treatment and that treatment may not be successful beyond a certain point in time.

At the present time, it is not possible to predict if an individual with a varicocele will have normal fertility even if treated early. However, preliminary studies have shown that when individuals with a varicocele and a smaller left testis are treated early, their chances of achieving normal fertility are significantly improved compared to untreated patients.

The indication for varicocele surgery in adult men is usaully based upon documented infertility and an abnormal semen specimen. In adolescents, the decision for surgery cannot be based upon these criteria since infertility is not documented and it is exceedingly difficult to obtain a semen specimen. However, it is not reasonable to withhold treatment of all adolescents with a varicocele since some of these individuals, if left untreated, may become sterile. Similarly, the present information does not support performing varicocele surgery upon every individual with a varicocele since not all of these individuals will become infertile.

The exact guidelines for recommending varicocele surgery in adolescents are still unresolved, however, at the present time, most experts agree that surgical correction should be considered when one or more of the following abnormalities is present:
  1. abnormal semen analysis;
  2. smaller testicle ont he same side as the varicocele;
  3. varicocele involving both the right and left sides.
However, it is difficult to be dogmatic since no one knows all the answers and certainly, fertility cannot be guaranteed even with surgery.

When surgery is not recommended, all individuals with a varicocele should be followed with annual testicular exams to insure that the testicles are growing normally, and after 17 years of age, and annual semen analysis is recommended. As long as the testicular exam and semen analysis remain normal, no intervention is required. However, it is important to recognize that a single normal semen analysis does not guarantee normal fertility because new abnormalities may develop over time. Therefore, it is important to have an annual check-up until that individual has completed his family.

Bibliography
Kass EJ. Adolescent varicocele: current concepts. Seminars in Urol 6(2):140-145, 1998.

Kass EJ. Evaluation and management of the adolescent with a varicocele. AUA Update Series 9:90-96, 1990.

Kass EJ and Belman AB. Reversal of testicular growth failure by varicocele ligation. J Urol 137:475-476, 1987.

Kass EJ, Chandras RS and Belman AB. Testicular histology in the adolescent with a varicocele. Pediatrics 79:996-008, 1987.

Kass EJ. Management of pediatric and adolescent varicocele. In Advances In Problems In Urology, Kramer SA and Pualson DF (eds). Philadelphia: J.B. Lippincott Company 4:690-704, 1990.

Kass EJ: Pediatric Varicocele. In Pediatric Urology. O'Donnell B and Doff SA (eds). Great Britain: The University Press 49:609-617, 1997.

Salisz JA, Kass EJ and Steinert BW. The significance of elevated scrotal temperature in an adolescent with a varicocele. In Temperature and Environmental Effects on the Testis. Zorgnioti AW (ed). New York, Plenum Press, 245-251, 1991.

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