Varicocele, Pediatric

Basics

Description

- Associated with anatomy of left testicular vein - Inserts into renal vein at right angle (right testicular vein drains into vena cava) - Incompetent or absent valves - Left testicular vein 8 " 10 cm longer than right, with increased pressure - Increased venous pressure from "nutcracker phenomenon " : compression of left renal vein as it passes between aorta and superior mesenteric artery

A varicocele is an abnormal tortuosity and dilation of the testicular veins and the pampiniform venous plexus of the spermatic cord.

Epidemiology

Incidence

Rare in prepubertal boys, increases with age to approximately 15% in late adolescence and healthy adult population2 " 10 years old, <1%11 " 14 years old, 7.8%15 " 19 years old, 14.1%
Based on World Health Organization observational study (1992), 15 " 20% of adult varicocele patients have fertility problems.Varicocele presents in 25% of men with abnormal semen analysis and 12% of men with normal semen parameters.Present in 35 " 40% of males with primary infertility
Left-sided predominance, 90%
No racial predilection

Risk Factors

Exact mechanisms have not been fully elucidated.
May be related to physiologic changes in puberty, such as rapid testicular growth and increased testicular blood flow
Associated with increased height and low body mass index
Increased risk in 1st-degree relatives of patients with a varicocele

Pathophysiology

Association between varicocele and testicular dysfunction/fertility compromiseImpaired spermatogenesis: decreased motility, decreased density, and increased number of pathologic sperm forms
Ipsilateral testicular hypotrophyRecent data demonstrates correlation between varicocele grade and testicular hypotrophy, although not observed in prior studies.Testicular "catch-up growth " after varicocelectomyCatch-up growth in 30 " 50% of patients managed conservatively
Potential field defect, affecting growth of bilateral testicles
Exact mechanisms not clearly elucidated " multiple theories:Hyperthermia: Varicocele increases intratesticular temperature, likely by interfering with the pampiniform plexus ' ability to provide countercurrent cooling system.Potential reflux of renal and adrenal metabolites, causing testicular damageIncreased production of nitric oxide and reactive oxygen species correlate with severity of varicocele.Endocrine abnormalities are found in subset of patients with varicocele, including low testosterone, abnormal response to gonadotropin-releasing hormone (GnRH), and impaired Leydig cell function.

Etiology

Associated with anatomy of left testicular veinInserts into renal vein at right angle (right testicular vein drains into vena cava)Incompetent or absent valvesLeft testicular vein 8 " 10 cm longer than right, with increased pressureIncreased venous pressure from "nutcracker phenomenon " : compression of left renal vein as it passes between aorta and superior mesenteric artery

Diagnosis

History

Often asymptomatic and incidentally noted on routine physical examInfertility not common issue in adolescent populationAssociated pain/heaviness/dull ache in 2 " 11% of cases
Laterality
Age of onset
When and how testicular abnormality first detected
Change in size of varicocele with positioning or Valsalva
Prior surgery or trauma
Prior imaging

Physical Exam

Examine in warm room when patient is supine and standing.
Palpate at rest and with Valsalva.
Para- and supratesticular mass; feels like a "bag of worms "
Assess size and consistency.
Estimate testicular volume with orchidometer, calipers, or color Doppler ultrasound.Right testicle serves as control for left.>2 mL or >20% size discrepancy, right > left, is significant.
Varicocele gradeGrade 1 (small): palpable only with ValsalvaGrade 2 (medium): easily palpable but not visibleGrade 3 (large): visible through scrotal skin
Varicocele should decompress in supine position.
Solitary right varicocele or failure of vessels to decompress in supine position raises concern for potential retroperitoneal or abdominal mass.

Diagnostic Tests & Interpretation

Color Doppler scrotal ultrasound to diagnose varicocele and estimate testicular volume
Semen analysis in age-appropriate patients
GnRH simulation test leads to increased FSH and LH response.Has not conclusively been shown to be good predictor of postsurgical improvement in adolescents

Differential Diagnosis

Epididymal cyst/spermatocele
Testicular mass
Epididymal mass
Paratesticular mass
Inguinal hernia
Hydrocele
Cord lipoma

Alert

Secondary varicocele, especially right-sided, can be a clinical indicator of retroperitoneal mass or venous obstruction. It is important to do physical exam standing and in supine position to assess for decompression of varicocele in supine position.

Treatment

Treatment is not indicated in all children/adolescents with varicocele.
Annual ultrasound assessment of testicular volume recommended.Potential for interobserver variability for imagingSpontaneous catch-up growth in some patients managed conservatively.
80 " 85% of men with varicocele do not exhibit effect on fertility.
Definitive treatment is recommended for the following:Size discrepancy between right and left testicle of >2 mL or 20%Adolescents with abnormal semen analysis and high-grade varicoceleAdolescents with symptoms: pain, heavinessAdolescents with bilateral varicocele
Treatment optionsSurgical ligation and division of testicular veins (laparoscopic vs. subinguinal approach)Testicular artery- and lymphatic-sparing reduces risk of secondary hydrocele.Intravenous embolization of testicular veins

Ongoing Care

Follow-up Recommendations

Persistence should be assessed by surveillance ultrasound 6 months after repair.
Trans-scrotal US to assess for testicular catch-up growth
Semen analysis to see if improvement in semen parameters

Prognosis

After repair, recurrence can occur in 1 " 16% of patients (depending on surgical technique).

Complications

Recurrent/persistent varicocele
Secondary hydroceleMay require surgery if symptomatic
Testicular hypotrophy/atrophy
Persistent fertility compromise

Additional Reading

Evers JH, Collins J, Clarke J. Surgery or embolisation for varicoceles in subfertile men. Cochrane Database Syst Rev. 2009;(3):CD000479. [View Abstract]
Preston MA, Carnat T, Flood T, et al. Conservative management of adolescent varicoceles: a retrospective review. Urology. 2008;72(1):77 " 80. [View Abstract]
Robinson SP, Hampton LJ, Koo HP. Treatment strategy for the adolescent varicocele. Urol Clin North Am. 2010;37(2):269 " 278. [View Abstract]
Serefoglu EC, Saitz TR, La Nasa JA Jr, et al. Adolescent varicocoele management controversies. Andrology. 2013;1(1):109 " 115. [View Abstract]
Stahl P, Schlegel PN. Standardization and documentation of varicocele evaluation. Curr Opin Neurol. 2011;21(6):500 " 505. [View Abstract]

Codes

ICD09

ICD10

SNOMED

46871008 scrotal varices (disorder)

FAQ

Q: What are long-term benefits of surgical repair of varicoceles?
A: If varicocele is corrected, testicular catch-up growth can occur when performed in adolescents, as well as decreased risk for infertility. In adult population, 2/3 of patients will have improvement in semen analysis, and 40% of their partners will become pregnant.
Q: Is there benefit of surgical repair of varicocele after puberty? Will this improve fertility?
A: Testicular hypotrophy does not improve after adult varicocelectomy. Although it appears to be a progressive process, studies have not clearly demonstrated clear benefit in fertility improvement if corrected in adolescence versus when fertility compromise is diagnosed.
Q: What happens if a varicocele is left untreated?
A: There is good evidence to show that when left untreated, a varicocele will continue to affect testicular growth with loss of volume and progressive deterioration in semen analysis.
Q: What is the risk of recurrence after repair?
A: Recurrence can occur in 1 " 16% of adolescents, depending on surgical technique.