A varicocele is an abnormal enlargement of the veins of the testicle that usually does not produce any symptoms. The majority of adolescents diagnosed with a varicocele are identified during a routine physical examination that demonstrates a non-tender enlargement of the veins of the testicle. Varicoceles are classified as Grade I (small), Grade II (medium), or Grade III (large).
A varicocele is the most common cause of infertility in adult men. 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 testicle 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. Data suggests that in some adolescent males, a varicocele has a significant effect upon testicular growth and function. In these individuals, early treatment is preferred because if treatment is delayed, this process may not be reversible. However, in other individuals, the effect of the varicocele is limited. In these circumstances, careful observation and close follow-up is recommended.
Anatomy
A varicocele most commonly involves the left testicle, but it can also, occasionally, 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 of a varicocele is defective valves within the testicular vein allowing a reversal of the normal blood flow.
Effects of Varicocele
At the present time, there is solid 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 of both testes. The effect of this temperature increase on the testis will vary from person to person since not all men with a varicocele will be infertile. However, it 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 varicocele 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, studies have shown that when individuals with a varicocele and smaller left testicle are treated early, their chances of achieving normal fertility are significantly improved compared to untreated patients.
Treatment of Varicocele
The indication for varicocele surgery in adult men is usually 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 sample. However, it is not reasonable to withhold treatment of all adolescents with a varicocele since some of these individuals, if left untreated, may become infertile. Similarly, there is not data to 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 if one of the following abnormalities is present:
- Abnormal semen analysis;
- Smaller testicle on the same side as the varicocele;
- Varicocele involving both the right and left sides.
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. In addition, after 17 years of age, an 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.
Varicocele repair presents relatively few risks. Increased fluid around the testicles (hydrocele) occurs in a small percentage of cases. Recurrence of varicoceles is a risk, affecting perhaps 2% - 3% who undergo repair. Repair methods include:
Open surgery
This most common form of treatment usually is done on an outpatient basis, using general anesthetic. We approach the vein through an incision in the abdomen (retroperitoneal). The dilated veins are identified and tied off. Recovery after surgical repair usually proceeds rapidly. Your doctor may advise you to return to normal activities that aren't strenuous after two days. As long as you're not uncomfortable, you may return to more strenuous normal activity, such as exercising, after four weeks. Pain resulting from this surgery is generally mild. Your doctor may prescribe pain medication for the first two days after surgery. After that, your doctor may advise you to take over-the-counter (OTC) painkillers, such as acetaminophen (Tylenol, others) to relieve discomfort.
Laparoscopic surgery
With this approach, your surgeon makes 3 tiny incisions in your abdomen and passes tiny instruments through the incisions to see and to repair the varicocele. The laparoscopic approach offers the same success as the open repair.