PEDIATRICS Vol. 114 No. 6 December 2004, pp. 1669-1670 (doi:10.1542/peds.2004-1273)
COMMENTARY |
The Adolescent Varicocele
Chairman Emeritus
Department of Pediatric Urology
Children’s National Medical Center
George Washington University
Washington, DC 20010
Just as all adolescent males should be educated by their primary care physicians about testicular self-examination and the symptoms of testicular torsion, they should also be routinely examined in the upright position. In this issue of Pediatrics, Salzhauer et al1 report the potential advantages of the early recognition and treatment of the adolescent varicocele.
The observation that varicoceles affect ipsilateral testicular growth and that this growth arrest can be reversed reportedly dates back to Bennett in an article in The Lancet in 1889. However, this information was apparently lost, and it was not until 1977, when Lipschultz and Corriere2 noted progressive ipsilateral testicular volume loss in adults with varicoceles, that attention became refocused on this problem. Based on their report and the fortuitous observation in an adolescent patient with a varicocele of a significantly smaller left testis as compared with the right, Kass and Belman3 prospectively compared testicular size before and after varicocele ligation. Testicular "catch-up" growth occurred in 80% postoperatively. Subsequently, as noted in the article by Salzhauer et al,1 this has been repeatedly substantiated.
However, satisfactory evidence that fertility is improved by correction of the adolescent varicocele is lacking. I am unaware of any controlled prospective study that proves that fertility is negatively affected by varicoceles, although it is well accepted that varicoceles are the leading cause of reversible infertility in adult men. However, when varicoceles are corrected in the infertile adult, fertility results in only 50% of patients. Equally, there have been no controlled prospective studies in adolescents to demonstrate that infertility or reduced fertility potential can be improved by early correction. As stated, it has been proven that hypotrophy can be reversed surgically, and there is evidence that testicular function is negatively impacted by varicoceles in adolescence.4,5
Okuyama et al6 published the first study to attempt to prospectively compare an operated versus nonoperated group of adolescents.5 However, their groups were neither randomly selected nor matched. In the 24 patients with surgical correction of their varicoceles, there were more with resolution of testicular hypotrophy, with none progressing to hypotrophy postoperatively. These were compared with 16 who elected not to have their varicocele corrected. There were also more normal semen parameters including sperm density, motility, and percentage of normal spermatozoa in the corrected group, as compared with the uncorrected group.
The report in this issue of Pediatrics seems to confirm that early surgery, before the onset of infertility, may be advantageous. It is known that infertility secondary to varicoceles (and therefore testicular damage) is a progressive problem. Therefore, it seems logical that the earlier the problem is resolved, the greater the likelihood of success (success being defined as fertility). The report by Salzhauer et al1 suggests that not only may infertility be prevented by early varicocele resolution but also that fertility itself may be enhanced above normal by the procedure. Of course, this defies logic, but we all know that medicine is not logical.
I tried to carry out a similar study by sending letters to a group of patients who had varicocele ligation between 1980 and 1990. Sixty letters were sent with such a poor response rate that the data could not be interpreted. Unfortunately, our population base in Washington, DC, does not seem to be as stable as the Hasidic group in New York. However, of the responses from 6 men who had tried to father children, all reported success. Similar to the conclusion of Salzhauer et al, the numbers are too small to suggest anything but a trend.
As should be the case when dealing with a problem that causes no symptoms and the result is theoretical, skepticism should exist as to the necessity for surgical correction. However, the decision for or against surgery should be in the hands of the educated patient and his family. Recognition of the presence of a varicocele becomes an important part of the evaluation of the adolescent male, because varicoceles are present in 
15% of the population and are therefore fairly common. It always amazes me to see one of these boys with a varicocele visible from across the room who states he was unaware of a problem until it was brought to his attention by his pediatrician. Of course, this could be denial.
Options regarding management include surgical correction, semen analysis with surgical correction based on those results, or waiting until infertility is proven. In our practice, we have been unsuccessful in getting adolescent boys to agree to a masturbated semen specimen. Additionally, some of the boys are peripubertal, and there is little information regarding normal semen parameters in early adolescence. Most boys and their parents, when given the information regarding risks and benefits, choose surgery. It is a simple procedure done either open or laparoscopically as an outpatient with excellent results.
Therefore, examination of the adolescent male to identify the presence of a varicocele should be routine for the practicing pediatrician. Identification of a varicocele should prompt referral to a pediatric urologist and the determination as to treatment made as objectively as possible. Most urologists base their decision on either the size of the varicocele, testicular size, or both. If the varicocele is large, the growth of both testicles may be affected. I have seen boys who, a few weeks after ligation of the left spermatic veins, return with significant growth of both testicles that cannot be explained by pubertal development alone. Kass et al7 have also observed a bilateral hypertrophy from a unilateral varicocele. It is hard to imagine that fertility would not be affected in patients such as these.
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FOOTNOTES |
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Accepted Jun 28, 2004.
Address correspondence to A. Barry Belman, MD, MS, 111 Michigan Ave NW, Washington, DC 20010. E-mail: abbelman{at}cnmc.org
No conflict of interest declared.
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REFERENCES |
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 TOP REFERENCES |
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- Salzhauer EW, Sokol A, Glassberg KI. Paternity after adolescent varicocele repair.
Pediatrics. 2004;114
:1631
–1633
[Abstract/Free Full Text] - Lipschultz LI, Corriere JN Jr. Progressive testicular atrophy in the varicocele patient. J Urol. 1977;117 :175 –176[Web of Science][Medline]
- Kass EJ, Belman AB. Reversal of testicular growth failure by varicocele ligation. J Urol. 1987;137 :476 –476
- Takihara H, Sakatoku J, Fujii M, Nasu T, Cosentino MJ, Cockett AT. Significance of testicular size measurement in andrology. I. A new orchiometer and its clinical application. Fertil Steril. 1983;39 :836 –840[Web of Science][Medline]
- Kass EJ, Freitas JE, Bour JB. Adolescent varicocele: objective indications for treatment. J Urol. 1989;142 :579 –582[Medline]
- Okuyama A, Nakamura M, Namiki M, et al. Surgical repair of varicocele at puberty: preventive treatment for fertility improvement. J Urol. 1991;146 :199 –204[Medline]
- Kass EJ, Stork BR, Steinhart BW. Varicocele in adolescence induces left and right testicular volume loss. BJU Int. 2001;87 :499 –501[Medline]
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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