http://www.jurology.

com/article/S0022-5347%2815%2904290-1/pdf

Review Article

Evaluation and Management of the Adolescent Varicocele

Thomas F. Kolon
From the Department of Urology (Surgery), Childrens Hospital of Philadelphia, Perelman School of Medicine at the University
of Pennsylvania, Philadelphia, Pennsylvania

Abbreviations
and Acronyms
AMH anti-mullerian hormone
FSH follicle-stimulating
hormone
GnRH gonadotropin-releasing
hormone
LH luteinizing hormone
LTV left testicular volume
RTV right testicular volume
TMC total motile count
TTV total testicular volume
TV testicular volume
TVdiff testicular volume
differential
Accepted for publication June 9, 2015.

Purpose: Varicocele is one of the most common genital conditions referred to

pediatric urologists. Most adolescents with varicocele are asymptomatic and
their fertility future (and surgery benefit) is largely unknown. This review assesses varicocele evaluation, management and indications for repair, as well as
types and success of varicocelectomy.
Materials and Methods: A systematic literature review was performed on
Embase, PubMed and Google Scholar for adolescent varicocele. Original
research articles and relevant reviews were examined, and a synopsis of these
data was generated for a comprehensive review of clinical adolescent varicocele
management.
Results: The prevalence of adolescent varicocele is similar to the adult population. While ultrasound is the most sensitive method for determining testicular
volumes, orchidometer measurement may be adequate to gauge significant
discordance. Significant hypotrophy of the affected testis with poor total testicular volume may indicate a testis at risk and warrant surgical repair. Similar
findings have been noted with an associated high peak retrograde venous flow.
Testicular hypotrophy often resolves following surgery but may also improve
spontaneously if followed through adolescence. Continued scrotal pain despite
adequate support or serial abnormal semen analysis in Tanner stage V boys is an
indication for varicocelectomy. Artery and lymphatic sparing techniques
(microscopic subinguinal or laparoscopic) are associated with the lowest risk of
recurrence and complications.
Conclusions: Overtreatment and under treatment are medically and financially
costly. Abnormal serial semen analysis with or without testicular hypotrophy is
an indication for varicocele repair. If observation remains the treatment, followup with an adult urologist should be encouraged until paternity is achieved.
Key Words: adolescent, infertility, semen analysis, testis, varicocele

VARICOCELE is among the most common genital issues referred to pediatric urologists. While the condition
is relatively uncommon in boys before
age 10 years, its prevalence increases
to 8% to 16% through puberty. In the
15 to 19-year-old age group the prevalence of varicocele is about 15%,
similar to that seen in the adult population.1 While varicocele repair in

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symptomatic men may improve

fertility potential, it has been estimated that 85% of men with varicocele will not encounter male factor
infertility.2 In contrast, most adolescents who present with varicocele
are asymptomatic and their fertility
future is unknown. Thus, evaluation and treatment of the adolescent
varicocele remain unclear and

0022-5347/15/1945-1194/0
THE JOURNAL OF UROLOGY
2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.

http://dx.doi.org/10.1016/j.juro.2015.06.079
Vol. 194, 1194-1201, November 2015
Printed in U.S.A.

EVALUATION AND MANAGEMENT OF ADOLESCENT VARICOCELE

controversial despite significant research during the

last several decades. This review will cover varicocele evaluation, management and indications
for repair, as well as types and success of
varicocelectomy.

EVALUATION
Evaluation of the patient with varicocele should be
geared toward identification of possible risk factors
associated with long-term subfertility. To this end,
the primary points of assessment have been varicocele grade, testicular volume (differential or
total), ultrasound venous investigation, endocrine
evaluation and semen analysis. Varicocele grade
(I, palpable when standing with Valsalva; II,
palpable when standing; III, visible when standing)
association with poor left testicular growth has been
variable. In adolescents a direct correlation between
varicocele grade and semen parameters has not been
observed. Some have correlated a higher grade with
poor ipsilateral growth, while Kass et al showed that
the right testis may similarly be at growth risk with
large grade III varicoceles.3 However, others have
observed no relationship.4e8 Thus, varicocele grade
alone is not an indicator for surgical repair.
Testicular size has been used by many authors to
gauge developing spermatogenic potential in
adolescent males with varicocele. The association of
varicocele with left testicular hypotrophy was
demonstrated several decades ago in adults and
subsequently in adolescents.9 Several studies have
revealed that left testicular hypotrophy may
improve after varicocele repair and so may represent a testis at risk.10e12
Significant LTV vs RTV differential has been
identified as 10% to 20%, or a 2 to 3 ml difference in
size. Possible testicular hypotrophy has generally
been evaluated as either an atrophy index compared
to the right, ie (RTV  LTV)/(RTV), or as a testicular volume differential similar to renal function
evaluation, ie TVDiff (RTV  LTV)/(TTV). Both
formulas are interchangeable, and differential TVs
can easily be converted from one formula to another
with near perfect accuracy.13
Paltiel et al measured testicular volume in
anesthesized dogs using Prader and Rochester
orchidometers, and then in vivo by ultrasound.14
The ultrasound measurements were calculated
using 2 formulas, ie volume length  width 
height  0.52 (volume of an ellipsoid) and volume
length  width  height  0.71 (Lambert formula).
These measures were compared to the volumes
definitively obtained by water displacement. Paltiel
et al found that ultrasound was more accurate than
orchidometry and the Lambert formula was superior to the formula of an ellipsoid for determining

1195

testicular volume.14 Diamond et al examined this

matter in humans and concluded that orchidometer
measurement is too insensitive to assess volume
differentials to determine growth impairment
compared to ultrasound.15 However, testis ultrasound measurement may also be somewhat imprecise regarding the placement of cursors for
determining length, width and depth. This inherent
variability seen in clinical practice is why many
have maintained that the decision for surgery
should not be based on a single measure at a single
point in time, but that several measures through
time will settle true significant asymmetry.
Recently Goede et al obtained reference data for
testicular volume measured by ultrasound in
asymptomatic boys 0.5 to 18 years old.16 For Tanner
stage V boys individual testis volumes ranged from
20 to 40 cm3. They found an accurate correlation
between volume measurements by ultrasound and
by the Prader orchidometer (R2 0.956), and
concluded that orchidometry can be used as a valid
parameter for monitoring testicular growth. The
exact method of testicular volume measurement is
left to the discretion of the urologist. The key point
is that a consistent method needs to be used to
obtain a reliable measure of testicular growth in an
individual adolescent through time.

MANAGEMENT
Management of the adolescent with varicocele remains controversial. Coutinho et al recently queried
members of the American Academy of Pediatrics
Section on Urology regarding varicocele management.17 They found that if significant testicular size
discrepancy is identified, 32% of practitioners
immediately intervene surgically, while 59% repeat
measurements in 6 to 12 months. When there is no
volume differential identified, 37% of practitioners
discharge their patients with no followup, 23% refer
to an infertility specialist and 31% evaluate with
semen analysis. Interestingly 57% of practitioners
had never sent patients for semen analysis.
Pastuszak et al similarly surveyed members of
the Society for Pediatric Urology.18 Most respondents operate for decreased ipsilateral testis
size, while some operate for varicocele grade alone.
Only 39% operate because of altered semen parameters, and 89% were unaware of the later
fertility status of the patients they operated on.
Unfortunately with a low response rate in both
surveys (28% to 54%) a definitive practice pattern
consensus could not be reached.
While some have argued for surgical correction if
the affected testicular volume is 10% to 20% less
than that of its contralateral normal mate, others
have noted that nearly 80% of these volume

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EVALUATION AND MANAGEMENT OF ADOLESCENT VARICOCELE

discrepancies resolve in time without surgery.7

Although early repair may prevent infertility, unrestricted repair of all adolescent varicoceles would
involve unnecessary surgery for the majority of patients.2 Delaying treatment until infertility is
shown in adulthood prevents unnecessary surgery
but may compromise outcomes, as approximately
30% of adults undergoing varicocele repair demonstrated no improvement in semen parameters.19
Similarly testicular hypotrophy does not usually
improve in adulthood, and varicocele damage may
be progressive through time in adults.20,21 Thus,
early repair during adolescence is attractive but
only if the correct predictors are found.
Several investigators have studied testicular
volume changes. Poon et al reported that 67% of
boys with greater than 15% TVdiff had persistent or
worse asymmetry after a median followup of
21 months.22 Van Batavia et al reported that catchup growth is rare when a peak retrograde venous
flow greater than 38 cm per second is associated
with a 20% or greater TVdiff (ie the 20/38
harbinger).23 They followed 53 boys who met either
the 20/38 (44 patients) or 15/38 (9) cutoffs for an
average of 15 months, and only 3 boys exhibited
catch-up growth to a differential of less than 15%.
To minimize subjectivity with this Doppler ultrasound test, it is important that the peak retrograde
flow be obtained with the patient supine and
achieving a satisfactory Valsalva maneuver.
Other groups have observed significant testicular
catch-up growth without surgery. Kolon et al followed 161 boys nonsurgically with scrotal ultrasound for a median of 39 months.7 Of the patients
54% initially had a 15% or greater TVdiff. After
2 years 85% had testicular volume differentials in
the normal range (less than 15%). Testis volume
differentials as large as 66% resolved without
intervention, and 71% of patients were spared
potential surgery based on size criteria.
Preston et al found normalization of left hypotrophy in boys 8 to 16 years old after a nonsurgical
median followup of 2.1 years.24 The catch-up growth
remained significant even after adjustment for age,
length of observation and need for surgery. Despite
this initial nonsurgical management, they caution
that those individuals who exhibit a testicular size
discrepancy that is steadily increasing should be
considered for surgical intervention.
Moursy et al compared surgical and nonsurgical
management of unilateral varicoceles in adolescents.25 Catch-up testicular growth was observed
in 70% of surgical patients and 50% of nonsurgical
patients, and semen analysis normalized in all
surgical patients and all but 1 patient in the
nonsurgical group. Testicular volume was not
different between the 2 groups.

Further research has examined the association of

testicular volume changes and semen analysis.
Diamond et al evaluated the relationship between
unilateral left varicocele grade or TVdiff and semen
parameters in adolescents.5 They found that TVdiff
greater than 10% correlated with decreased TMC.
While as a group comparison (less than 10% vs 10%
to 20% vs greater than 20%) there is more likelihood
of an abnormal TMC when there is a larger TVdiff,
there are also patients with normal range TMC in
all of the groups. Thus, they do not recommend
prophylactic surgery for all boys with more than a
10% differential. Rather, TVdiff greater than 10%
may serve as a marker for someone who is at risk for
subfertility and needs further followup. They also
noted that sperm morphology only improved when
there was also improvement in sperm concentration. Sperm morphology is an as yet undefined factor in the evaluation of adolescent varicocele.
Paduch and Niedzielski reported on 17 to 19-yearold boys with grades II and III varicoceles, and noted
poorer semen quality in those with greater backflow
velocity and greater asymmetry.10 Semen analysis in
adolescence is graded against the World Health Organization standards set for adult males.
Christman et al correlated serial ultrasound
TVdiff and TTV in patients followed for several
years with eventual semen analysis.26 TTV performed superiorly to TVDiff for predicting TMC but
none of the TV parameters analyzed had a simultaneously high sensitivity and specificity. TTV and
TVdiff had a small to moderate predictive ability for
a normal TMC. The authors concluded that
following TV through time affords a limited clinical
ability to differentiate patients based on the
outcome of TMC. It has also been noted that the
relationship between TVdiff and low total motile
sperm levels is not significant. However, when low
TTV is associated with marked asymmetry, total
motile sperm counts are at their lowest. Thus,
before the ability to obtain a semen analysis,
marked TVdiff with a low TTV may identify an
adolescent at risk.
Bogaert et al evaluated the ability to achieve
paternity in adults who had been diagnosed with
varicocele in adolescence and either underwent
antegrade sclerotherapy or received no further
treatment.27 They concluded that there is no beneficial effect to screening for varicocele, since treating
the varicocele at diagnosis does not appear to
improve later paternity. While some interval data
(Tanner stage, testicular volume through time,
semen analysis) were missing that might have helped
us treat adolescents/young adults, the findings
of Bogaert et al27 reinforce the historical data confirming that 80% to 85% of adults with varicocele do
not have paternity issues prompting an infertility

EVALUATION AND MANAGEMENT OF ADOLESCENT VARICOCELE

evaluation. Two-thirds of Tanner stage V boys with

an uncorrected varicocele achieve a normal TMC
regardless of varicocele grade or testicular volumes.
When these boys are sequentially followed with serial
semen analyses, 46% with an initial poor semen
analysis will improve to good status (normal TMC)
without surgery.28
Early studies of the rodent varicocele model and
the histology of the adolescent testis suggest some
element of Leydig cell dysfunction leading to an
intratesticular androgen environment that is inadequate for full Sertoli cell function and spermatogenesis.29,30 Hadziselimovic et al examined bilateral
testis biopsies at varicocele repair and noted
abnormal adult dark spermatogonia maturation.31
Ten-year followup revealed normal LH, FSH and
testosterone levels in all patients, and the investigators were unable to correlate histological
findings with abnormal semen parameters.
In addition to the possible effect on germ cells,
endocrine imbalances have been noted in individuals with varicocele. Damage to germinal
epithelium results in compensatory stimulation of
the pituitary gland and a resultant increase in FSH
and LH production. Kass et al reported that some
patients with varicocele have an exaggerated increase in LH and FSH secretion after exogenous
GnRH administration, implying a varicocele effect
on the hypothalamic-pituitary-gonadal axis.32
Recent data have also shown a correlation between the GnRH stimulation test, testicular hypotrophy and pathological semen analysis.33 However,
GnRH stimulation has not yet been demonstrated to
be helpful in identifying adolescents at risk for
future infertility. Since the GnRH test is fairly
expensive, requires multiple blood draws and lacks
a definite association between abnormal results,
testicular growth arrest and infertility, it has not
been universally adopted.
Romeo et al examined various androgen related
hormones associated with untreated varicoceles.34
In a small series of boys with testis volume differential measured at a single point in time they found
that inhibin B was decreased and positively correlated with testicular volume. However, all other
hormones (GnRH stimulated LH, FSH, testosterone) were normal, and there was no correlation
with semen parameters.
Trigo et al similarly compared untreated prepubertal and pubertal boys and adolescent controls,
and found that inhibin B levels were higher in prepubertal patients with varicocele than in controls,
with no further increment in inhibin B in the pubertal patients.35 Higher levels of AMH were found
in Tanner stage I, III, IV and V patients with varicocele compared to normal boys by Tanner stage.
The direct correlation found in normal boys between

1197

inhibin B levels and LH, testosterone and testicular

volume was not observed in patients with varicocele.
They concluded that the altered serum profile of
gonadal hormones observed in patients with untreated varicocele may indicate an early abnormal
regulation of the seminiferous epithelium function.
At this time there is not an absolute consensus on
hormonal evaluation of the adolescent varicocele.
Thus, we currently offer measurement of the hormones LH, FSH, testosterone, inhibin B and AMH,
which has been observed to be helpful in adults.

INDICATIONS FOR REPAIR

The American Urological Association Male Infertility Best Practice Policy Committee and the American Society for Reproductive Medicine Practice
Committee state that treatment of adult varicocele
should be considered when 1) varicocele is palpable
on physical examination, 2) the couple has known
infertility, 3) the female partner has normal fertility
or a potentially treatable cause of infertility and 4)
the male partner has abnormal semen parameters or
abnormal results on sperm function tests.36 However, these indications are rarely available in the
adolescent/young adult population. Varicocele
treatment for infertility is not indicated in patients
with either normal semen quality or a subclinical
varicocele. Varicocele repair in adolescents should be
considered when there is objective evidence of
reduced ipsilateral testicular size. In the absence of
objective evidence the committees recommend that
adolescents/young adults be followed with yearly
ultrasound or semen analysis to detect the earliest
signs of accelerated testicular injury.
The European Association of Urology recently
released similar guidelines, which state that
1) varicocele treatment is recommended for adolescents with progressive failure of testicular development documented by serial clinical examination,
2) there is no evidence indicating benefit of varicocele treatment in infertile men who have normal
semen analysis or a subclinical varicocele, and
3) varicocele repair should be considered in cases of
clinical varicocele, oligospermia, infertility duration
greater than 2 years and otherwise unexplained
infertility in the couple.37 Given the aforementioned
recent research of varicocele effect on testicular
volume, androgen levels and semen analysis, the
current adolescent recommendations for surgery
will likely be adjusted.

TREATMENT OPTIONS
Surgical options for varicocelectomy include the
open inguinal (Ivanissevich), high retroperitoneal
(Palomo ligation of testicular veins and artery) and

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EVALUATION AND MANAGEMENT OF ADOLESCENT VARICOCELE

subinguinal microsurgical approaches, as well as

laparoscopic repair (Palomo type mass ligation or
artery sparing). Antegrade or retrograde embolization or sclerotherapy is a nonsurgical option. Practice patterns among urologists vary widely in the
adult and adolescent populations.17,18
The key surgical question is whether adolescent
varicocele repair has any effect on reversal of
testicular hypotrophy or improvement in semen
parameters. While the ultimate patient goal is paternity, semen analysis is critical to appropriate
treatment of these patients. Several studies have
revealed catch-up growth in the varicocele treatment groups. One study randomized 15 to 19-yearold males with grade II to III varicoceles to surgery
or observation, and showed a reversal of testicular
growth arrest and catch-up growth within
12 months of surgery.10
Lenzi et al reported better semen parameters in
adults who underwent varicocele repair in adolescence compared to those who did not undergo
repair.38 Cayan et al demonstrated that varicocelectomy improved low sperm concentration in 15 to
19-year-old males with hypotrophy, even in those
who did not achieve catch-up growth.39 Randomized
controlled studies have also revealed improvement
in semen parameters only after varicocele
repair.11,12 Ku et al compared preoperative and
postoperative semen analyses between adolescents
and fertile and infertile adults with varicocele after
microsurgical varicocelectomy.40 There was no significant difference in sperm count, motility or
morphology among the 3 groups. While the adolescent group had better overall end points, they also
had better baseline semen parameters than the
adults, and the authors could not show a clear
advantage to early repair.
Kolon et al studied 14 consecutive adolescents
with preoperative and postoperative semen analyses.28 In that series mean preoperative TMC was
3.6 million (range 0 to 16.9 million) and mean postoperative TMC was 24.2 million (0.23 to 84.4
million). Of 14 patients 11 (78.6%) demonstrated
significant improvement (p 0.01) in TMC, with
7 patients moving into the normal adult range.
While they did not have a control group, comparison
to historical adult improvement in semen parameters reveals a slight advantage for adolescent repair.
The effect of lymphatic sparing on catch-up
growth was examined by Poon et al in 136 boys
(mean age 15 years) with greater than 10% TVdiff.22
Of the patients 107 were treated with laparoscopic
lymphatic sparing and 29 with nonlymphatic
sparing varicocelectomy. Catch-up growth was
achieved in 62.8% of patients but there was no significant difference between the 2 approaches regarding catch-up growth (51.7% vs 66.3%, p 0.19).

Complications of repair include hydrocele formation, persistence or recurrence of varicocele, and

testicular atrophy. In adults and adolescents subinguinal microscopic varicocelectomy is associated
with the lowest postoperative complication rate.
Postoperative improvements in semen analysis of
microsurgical repair are comparable to open
inguinal and laparoscopic varicocelectomy, with
lower rates of hydrocele formation or varicocele
recurrence.41
Hydrocele formation, reported in about 7% of
cases, is the most common complication after nonmicrosurgical varicocelectomy. Hydrocele formation
is thought to be due to ligation of the testicular
lymphatics. Approximately half of all postoperative
hydroceles are of a size that may warrant surgical
hydrocelectomy, although the effect of hydrocele
pressure on spermatogenesis and fertility is unknown. Use of the operating microscope has essentially eliminated development of hydroceles
following varicocelectomy due to the ability to easily
visualize and spare inguinal lymphatics.
The incidence of varicocele recurrence following
surgical repair varies from 1% to 45%. The rate of
recurrence depends on the type of procedure performed and the use of magnification. Venography has
shown that recurrent varicoceles are caused by
collateral periarterial, parallel inguinal, mid retroperitoneal, gubernacular and transscrotal veins.
Thus, some have recommended that dissection below
the inguinal cord with delivery of the testis affords
the best chance for ligation of all perforating external
spermatic veins and gubernacular veins, and is
associated with a 10% varicocele recurrence rate.
Testicular artery injury or ligation may cause
testicular atrophy and/or impaired spermatogenesis.
Microscopic or laparoscopic magnification and use of
a Doppler probe facilitate identification and preservation of the testicular artery. When the testicular
artery is ligated, as in a classic open or laparoscopic
Palomo repair, the patient should be cautioned that
future vasectomy might result in testicular atrophy.
Therefore, a deferential artery sparing vasectomy
should be recommended if desired.
Although most advocate surgical correction,
percutaneous varicocele embolization is a well
tolerated technique with a high benefit-to-cost
ratio. In men with grade III left varicocele,
abnormal sperm parameters and documented
infertility embolization is associated with a significant improvement in sperm concentration,
motility and morphology but not in serum testosterone, FSH or inhibin B levels. These results are
in contradistinction to findings at several centers
demonstrating improvement in hormonal levels
with surgical repair.42 Chuang et al followed
39 patients for 3 years after primary or salvage

EVALUATION AND MANAGEMENT OF ADOLESCENT VARICOCELE

Initial Presentation
Take History
Physical Exam (standing) to establish grade
Orchidometer to establish baseline volumes

Follow-up every 2 yrs

(if good volumes) with
orchidometer volume
until at least age 15
AND Tanner V

If no SA obtained/family refuses
or if not Tanner V

Follow-up in one year

Discuss SA again
Measure testes
with orchidometer

If SA refused at
age 16,
recommend f/u
at 18 for SA

1199

Grade Varicocele (standing)

I. Palpable with valsalva
II. Palpable at rest
III. Grossly visible

Follow-up annually (if

poor volumes) with
orchidometer volume
until at least age 15
AND Tanner V

Consider Surgery if
persistent low TTV
(<age 15)

Age 15/Tanner V
Obtain orchidometer volume,
semen analysis, labs (LH,
FSH, testosterone, inhibin B,
AMH)

TMC >20 million

TMC <20 million

Discuss repeat
SA and
orchidometer at
age 18

Repeat SA in 36 mos (repeat

labs if clinically
indicated)
TMC >20 million

Discuss repeat
SA and
orchidometer at
age 18

TMC <20 million

Surgical Repair
of Varicocele

Repeat SA and
orchidometer 36 mos after
surgery (repeat
labs if abnormal
preop)

Repeat SA and
orchidometer at
age 18

Evaluation and management algorithm for adolescent varicocele. f/u, followup. SA, semen analysis.

selective gonadal vein embolization.43 The postembolization complication rate was 7.5% and
1 patient in the primary treatment group reported
recurrence. However, concerns remain that
recurrence rates after percutaneous embolization
may be higher than the reported data due to
possible later recanalization through the coils.
Embolization also adds the radiological risk of
fluoroscopy, which is not encountered with other
surgical repairs.
For information on pregnancy rates based on type
of repair conclusions must be deduced from the
adult population. Cayan et al analyzed 36 studies to
define which technique affords the highest pregnancy rate after varicocele repair.39 They concluded
that microsurgical varicocelectomy is associated
with higher spontaneous pregnancy rates and less
postoperative recurrence compared to other

varicocelectomy techniques and radiological embolization in infertile men. Diegidio et al reviewed

pooled data from more than 5,000 patients in
33 studies.41 Overall pregnancy rate was 38% and
was highest for the microsurgical subinguinal
(45%) or microsurgical inguinal technique (42%),
compared to the Palomo procedure (34%), radiological embolization (32%), conventional inguinal
repair (31%) and the laparoscopic technique (28%).
In a meta-analysis (2 randomized controlled trials and 3 observational studies) Marmar et al
evaluated pregnancy rates after varicocelectomy
among men with grade I to III varicoceles and at
least 1 abnormal semen parameter.44 They
concluded that varicocele repair has beneficial
effects on fertility status (OR 2.87). Kim et al performed a similar meta-analysis and found a significant fixed effects pooled OR of 4.15.45

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EVALUATION AND MANAGEMENT OF ADOLESCENT VARICOCELE

Several investigators have evaluated the

response of hormones to varicocele repair. Fisch
et al examined the response in boys to GnRH
stimulation before and after unilateral varicocele
repair and associated testicular atrophy.46 The FSH
response to GnRH stimulation increased following
surgery but they noted that the GnRH stimulation
test could not be used to determine which adolescent would benefit from surgical repair. Others have
documented a postoperative increase in testosterone
in Tanner stage I to III cases but no differences in
basal LH and FSH or stimulated FSH. A decrease of
maximal LH response to GnRH stimulation was
noted postoperatively in Tanner stages IV and V.47
Testosterone response has primarily been evaluated in the adult population. Su et al noted a modest
increase in testosterone from 319 ng/dl preoperatively to 409 ng/dl (p <0.05) in infertile men,
although this finding did not necessarily cause a
direct improvement in semen quality.48 A metaanalysis revealed that mean serum testosterone
levels increased by 97.5 ng/dl after surgical correction of the adult varicocele.49 Hsiao et al showed
that microscopic varicocelectomy results in significant increases in testosterone regardless of varicocele grade,50 although the accompanying editorial
comment cautions that currently varicocele repair
should not be advocated for hypogonadism alone.
Further studies of greater number are needed to
fully evaluate the adolescent hormonal profile preoperatively and postoperatively with semen analysis correlation.

MANAGEMENT ALGORITHM
Overtreatment and under treatment are medically
and financially costly. Expensive ultrasound, office

visits and surgery must be avoided in those who do

not need this management, while early intervention is warranted in some to preempt the need for
later assisted reproductive techniques (although
no financial assessment of evaluation/treatment
options has been done in adolescents). Based on
current evidence, abnormal semen parameters are
the most reasonable measurements that are
potentially predictive of future fertility (see figure).
All boys with varicoceles should undergo assessment of testicular size (preferably with an orchidometer for cost savings) yearly, or every other
year if the total testicular volume is normal, until
the patient reaches Tanner V maturity. The patient can then be offered semen analysis and
perhaps androgen hormone levels, testing pituitary, Sertoli cell and Leydig cell function
(LH, FSH, testosterone, anti-m
ullerian hormone,
inhibin B). A semen analysis discussion with the
patient and family should consider any individual
ethical and religious concerns. If the total testicular volume is low, semen parameters are low,
androgen laboratory results are abnormal or the
patient is symptomatic (uncommon), varicocele
correction should be discussed.
As in adults, abnormal serial semen analyses
with or without testicular hypotrophy is an indication for varicocele repair. If observation remains the treatment, followup with an adult
urologist should be encouraged until paternity is
achieved.
It seems that all patients with varicocele should
be followed into adulthood if we wish to determine
the best parameters in adolescence that predict
adult fertility. Only then will we really know
whether we are making a difference in the overall
testicular health of these patients.

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of varicocele and varicocele-related testicular
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2. Skoog SJ, Roberts KP, Goldstein M et al: The
adolescent varicocele: whats new with an old
problem in young patients? Pediatrics 1997; 100:
112.
3. Kass EJ, Stork BR and Steinert BW: Varicocele in
adolescence induces left and right testicular
volume loss. BJU Int 2001; 87: 499.
4. Alukal JP, Zurakowski D, Atala A et al: Testicular
hypotrophy does not correlate with grade of
adolescent varicocele. J Urol 2005; 174: 2367.
5. Diamond DA, Zurakowski D, Bauer SB et al:
Relationship of varicocele grade and testicular

hypotrophy to semen parameters in adolescents.

J Urol 2007; 178: 1584.
6. Steeno O, Knops J, Declerck L et al: Prevention
of fertility disorders by detection and treatment
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7. Kolon TF, Clement MR, Cartwright L et al:
Transient asynchronous testicular growth in
adolescent males with a varicocele. J Urol 2008;
180: 1111.
8. Kass EJ and Belman AB: Reversal of testicular
growth failure by varicocele ligation. J Urol
1987; 137: 475.
9. Lipshultz LI and Corriere JN Jr: Progressive
testicular atrophy in the varicocele patient.
J Urol 1977; 117: 175.

10. Paduch DA and Niedzielski J: Semen analysis in

young men with varicocele: preliminary study.
J Urol 1996; 156: 788.
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