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

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

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.
pediatric urologists. Most adolescents with varicocele are asymptomatic and
their fertility future (and surgery benefit) is largely unknown. This review as-
sesses 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 popula-
tion. 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 testic-
ular 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, fol-
lowup with an adult urologist should be encouraged until paternity is achieved.

Key Words: adolescent, infertility, semen analysis, testis, varicocele

VARICOCELE is among the most com- symptomatic men may improve

mon genital issues referred to pedi-
atric 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 prev-
alence of varicocele is about 15%,
similar to that seen in the adult pop-
ulation.1 While varicocele repair in
fertility potential, it has been esti-
mated that 85% of men with varico-
cele will not encounter male factor
infertility.2 In contrast, most adoles-
cents who present with varicocele
are asymptomatic and their fertility
future is unknown. Thus, evalua-
tion and treatment of the adolescent
varicocele remain unclear and

0022-5347/15/1945-1194/0 http://dx.doi.org/10.1016/j.juro.2015.06.079

1194 j www.jurology.com
THE JOURNAL OF UROLOGY
2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.
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 varico-
cele 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 vari-
cocele 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 repre-
sent 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 testic-
ular 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 supe-
rior 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 ultra-
sound measurement may also be somewhat impre-
cise 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 re-
mains controversial. Coutinho et al recently queried
members of the American Academy of Pediatrics
Section on Urology regarding varicocele manage-
ment.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 re-
spondents operate for decreased ipsilateral testis
size, while some operate for varicocele grade alone.
Only 39% operate because of altered semen pa-
rameters, 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
1196 EVALUATION AND MANAGEMENT OF ADOLESCENT VARICOCELE
discrepancies resolve in time without surgery.7
Although early repair may prevent infertility, un-
restricted repair of all adolescent varicoceles would
involve unnecessary surgery for the majority of pa-
tients.2 Delaying treatment until infertility is
shown in adulthood prevents unnecessary surgery
but may compromise outcomes, as approximately
30% of adults undergoing varicocele repair demon-
strated 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 catch-
up 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 ultra-
sound 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 fol-
lowed 161 boys nonsurgically with scrotal ultra-
sound 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 hypo-
trophy 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 adoles-
cents.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 concentra-
tion. Sperm morphology is an as yet undefined fac-
tor in the evaluation of adolescent varicocele.
Paduch and Niedzielski reported on 17 to 19-year-
old 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 Or-
ganization 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 per-
formed superiorly to TVDiff for predicting TMC but
none of the TV parameters analyzed had a simul-
taneously 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 bene-
ficial 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 con-
firming 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 inad-
equate for full Sertoli cell function and spermato-
genesis.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 in-
vestigators 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 in-
dividuals 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 in-
crease 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 be-
tween the GnRH stimulation test, testicular hypo-
trophy 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 differ-
ential measured at a single point in time they found
that inhibin B was decreased and positively corre-
lated with testicular volume. However, all other
hormones (GnRH stimulated LH, FSH, testos-
terone) were normal, and there was no correlation
with semen parameters.
Trigo et al similarly compared untreated prepu-
bertal and pubertal boys and adolescent controls,
and found that inhibin B levels were higher in pre-
pubertal patients with varicocele than in controls,
with no further increment in inhibin B in the pu-
bertal patients.35 Higher levels of AMH were found
in Tanner stage I, III, IV and V patients with vari-
cocele 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 un-
treated 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 hor-
mones LH, FSH, testosterone, inhibin B and AMH,
which has been observed to be helpful in adults.
INDICATIONS FOR REPAIR
The American Urological Association Male Infer-
tility Best Practice Policy Committee and the Amer-
ican 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 Howev-
er, 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 adoles-
cents with progressive failure of testicular devel-
opment documented by serial clinical examination,
2) there is no evidence indicating benefit of varico-
cele 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
1198 EVALUATION AND MANAGEMENT OF ADOLESCENT VARICOCELE
subinguinal microsurgical approaches, as well as
laparoscopic repair (Palomo type mass ligation or
artery sparing). Antegrade or retrograde emboliza-
tion or sclerotherapy is a nonsurgical option. Prac-
tice 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 pa-
ternity, semen analysis is critical to appropriate
treatment of these patients. Several studies have
revealed catch-up growth in the varicocele treat-
ment groups. One study randomized 15 to 19-year-
old 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 adoles-
cence compared to those who did not undergo
repair.38 Cayan et al demonstrated that varicoce-
lectomy 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 sig-
nificant difference in sperm count, motility or
morphology among the 3 groups. While the adoles-
cent 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 anal-
yses.28 In that series mean preoperative TMC was
3.6 million (range 0 to 16.9 million) and mean post-
operative 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 parame-
ters 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 sig-
nificant difference between the 2 approaches regard-
ing catch-up growth (51.7% vs 66.3%, p 0.19).
Complications of repair include hydrocele for-
mation, persistence or recurrence of varicocele, and
testicular atrophy. In adults and adolescents sub-
inguinal 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 non-
microsurgical 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 un-
known. Use of the operating microscope has essen-
tially 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 per-
formed and the use of magnification. Venography has
shown that recurrent varicoceles are caused by
collateral periarterial, parallel inguinal, mid retro-
peritoneal, 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 preser-
vation 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 sig-
nificant improvement in sperm concentration,
motility and morphology but not in serum testos-
terone, 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 1199

Initial Presentation Grade Varicocele (standing)

Take History I. Palpable with valsalva
Physical Exam (standing) to establish grade II. Palpable at rest
Orchidometer to establish baseline volumes III. Grossly visible

Follow-up every 2 yrs Follow-up annually (if

(if good volumes) with poor volumes) with Consider Surgery if
orchidometer volume orchidometer volume persistent low TTV
until at least age 15 until at least age 15 (<age 15)
AND Tanner V AND Tanner V

If no SA obtained/family refuses Age 15/Tanner V

or if not Tanner V Obtain orchidometer volume,
semen analysis, labs (LH,
FSH, testosterone, inhibin B,
AMH)
Follow-up in one year
Discuss SA again TMC >20 million
TMC <20 million
Measure testes
with orchidometer

Discuss repeat Repeat SA in 3-

SA and 6 mos (repeat
If SA refused at orchidometer at labs if clinically
age 16, age 18 indicated)
recommend f/u
at 18 for SA TMC >20 million TMC <20 million

Discuss repeat
SA and Surgical Repair
orchidometer at of Varicocele
age 18

Repeat SA and
orchidometer 3-
6 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 post-
embolization 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 preg-
nancy 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 embo-
lization 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%), radiolog-
ical embolization (32%), conventional inguinal
repair (31%) and the laparoscopic technique (28%).
In a meta-analysis (2 randomized controlled tri-
als 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 per-
formed a similar meta-analysis and found a signif-
icant fixed effects pooled OR of 4.15.45
1200 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 adoles-
cent 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 evalu-
ated in the adult population. Su et al noted a modest
increase in testosterone from 319 ng/dl preopera-
tively 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 meta-
analysis revealed that mean serum testosterone
levels increased by 97.5 ng/dl after surgical correc-
tion of the adult varicocele.49 Hsiao et al showed
that microscopic varicocelectomy results in signifi-
cant increases in testosterone regardless of varico-
cele 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 pre-
operatively and postoperatively with semen anal-
ysis 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 interven-
tion 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 assess-
ment of testicular size (preferably with an orchi-
dometer for cost savings) yearly, or every other
year if the total testicular volume is normal, until
the patient reaches Tanner V maturity. The pa-
tient can then be offered semen analysis and
perhaps androgen hormone levels, testing pitui-
tary, 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 testic-
ular 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 indi-
cation for varicocele repair. If observation re-
mains 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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