The varicocele is a painless dilatation of the veins of the pampinaform plexus and has a known association with male infertility. However, not every man with a varicocele is infertile. Some have estimated that, of men with a varicocele, only 13% have infertility.
The incidence of varicocele in the adolescent male population is approximately 15% in those older than 15, and 0 in those under 10.
A varicocele is typically detected during physical examination as a palpable nontender “bag of worms” noted in the left hemiscrotum with the patient in the standing position. Right-sided varicoceles and bilateral varicoceles are unusual. All groin and scrotal examinations should be made with the patient in the upright position. The ipsilateral testicle is palpated for size and consistency as well as the contralateral testicle. Studies have suggested that the varicocele can cause atrophy of the ipsilateral testicle and sometimes the contralateral testicle and that varicocele ligation can restore testicular volume in many adolescents. Histologically, the pathologic testicular changes associated with varicoceles in adolescents are somewhat similar to those seen in infertile adults with a varicocele and are progressive, suggesting that the duration of the varicocele correlates with the degree of testicular injury.
Presently, the ipsilateral testicular volume is a guide toward the indication for varicocele ligation in the adolescent.
Tests such as semen analysis in the pubescent male may be difficult to obtain. Research suggests that endocrine studies in the form of an exaggerated response of LH and FSH to gonadotropin-releasing hormone (GNRH) my be useful in identifying those who may benefit from varicocele surgery. This response has been normalized in patients with improved sperm density after varicocele ligation.
The adolescent with a varicocele presents a dilemma in management because the risk of future infertility to the individual patient is unknown. Varicocele ligation is recommended in those with:
- a varicocele in the presence of a testicle smaller than the contralateral testicle;
- abnormal semen analysis, if obtainable;
- abnormal response to an infusion of GNRH; and
- any worsening of the above on annual examinations.
Varicocele surgery may be performed as an outpatient under a general anesthetic either laparoscopically or through a small incision. We usually perform the surgery using a small suprainguinal retroperitoneal incision rather than laparoscopically, as it is quicker and just as complete.