A common referral for a urologist, especially for those with a focus on infertility, is for the evaluation of a 13, 14 or 15 year old boy who is discovered by his pediatrician to have a large left varicocele, or abnormally dilated veins in the scrotum. Even if there are no symptoms associated with the findings, there is some cause for concern as varicoceles can sometime predispose to later fertility problems and their correction can sometimes improve, or in the case of adolescents, actually prevent later fertility issues. In addition, there has also been recent attention to a possible hormonal effect of varicoceles on testosterone in some individuals.
As part of the evaluation urologists will commonly order a scrotal ultrasound to evaluate for other scrotal pathology and to enable an accurate measurement of testis volume; if there is a significant volume discrepancy, varicocele repair may be appropriate. In fact, if there is early intervention with varicocelectomy, “catch up growth” of the smaller testicle is common. Once adulthood is reached, there is no catch up growth with ligation.
Varicocele ligation is performed as an outpatient minor surgical procedure and risks of the procedure are low, with the most common being “hydrocele” (residual fluid around the testicle) which in reported series can occur in up to 3% of individuals; however, use of the microsurgical approach has reported hydrocele rates of well below one percent.
On the other hand, series have shown that some adolescents will have catch up growth without a procedure. This has led to some championing a wait and see approach. In that approach, the adolescent is observed until adulthood at which time a semen analysis, hormone related blood test and repeat testicular size measurement is performed. Varicocele correction might be considered in the setting of either worsening testicular size disparity during observation, an abnormality in total testicular volume, abnormal hormone test results and or abnormal findings on semen analysis .
So, in the first scenario, doctors would be attempting to prevent a fertility issue, but might do so at the expense of correcting some varicoceles that would not have caused a problem in the first place. In the second scenario, doctors are trying to reverse what may be a fertility problem that has already taken root and is possibly less responsive to treatment.
Finally, there is a criteria for early intervention called the “20/38” rule which holds that when the size discrepancy between the two testes is greater than twenty percent and when the “peak systolic velocity” (a measurement of blood flow on ultrasound) is greater than 38 cm/sec, the chance that there will be catch up growth without a procedure is very unlikely and therefore intervention is recommended.
When considering whether or not to proceed with varicocele repair in an adolescent, best outcomes may be achieved by working with a urologist familiar with all of these issues and considerations.
