Levels of evidence (1a-4) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
Background
Varicocele is defined as an abnormal dilatation of testicular veins in the pampiniformis plexus caused by venous reflux. It is unusual in boys under 10 years of age and becomes more frequent at the beginning of puberty. It is found in 15%-20% of adolescents, with a similar incidence during adulthood. It appears mostly on the left side (78%-93% of cases). Right-sided varicoceles are least common; they are usually noted only when bilateral varicoceles are present and seldom occur as an isolated finding.
Varicocele develops during accelerated body growth by a mechanism that is not clearly understood. Varicocele can induce apoptotic pathways because of heat stress, androgen deprivation and accumulation of toxic materials. Severe damage is found in 20% of adolescents affected, with abnormal findings in 46% of affected adolescents. Histological findings are similar in children or adolescents and in infertile men. In 70% of patients with grade II and III varicocele, left testicular volume loss was found. However, studies correlating a hypoplastic testicle with poor sperm quality have reported controversial results.
Several authors reported on reversal of testicular growth after varicocelectomy in adolescents (Level of evidence: 2). However, this may partly be attributable to testicular oedema associated with the division of lymphatic vessels (Level of evidence: 2).
In about 20% of adolescents with varicocele, fertility problems will arise. The adverse influence of varicocele increases with time. Improvement in sperm parameters has been demonstrated after adolescent varicocelectomy (Level of evidence: 1).
Diagnosis
Varicocele is mostly asymptomatic, rarely causing pain at this age. It may be noticed by the patient or parents, or discovered by the paediatrician at a routine visit. The diagnosis depends upon the clinical finding of a collection of dilated and tortuous veins in the upright posture; the veins are more pronounced when the patient performs the Valsalva manoeuvre.
Varicocele is classified into 3 grades: Grade I - Valsalva positive (palpable at Valsalva manoeuvre only); Grade II - palpable (palpable without the Valsalva manoeuvre); Grade III - visible (visible at distance). The size of both testicles should be evaluated during palpation to detect a smaller testis.
Venous reflux into the plexus pampiniformis is diagnosed using Doppler colour flow mapping in the supine and upright position. Venous reflux detected on ultrasound only is classified as subclinical varicocele. The ultrasound examination includes assessment of the testicular volume to discriminate testicular hypoplasia. In adolescents, a testis that is smaller by more than 2 mL compared to the other testis is considered to be hypoplastic (Level of evidence: 4).
In order to assess testicular injury in adolescents with varicocele, supranormal follicle-stimulating hormone (FSH) and luteinizing hormone (LH) responses to the luteinizing hormone-releasing hormone (LHRH) stimulation test are considered reliable, as histopathological testicular changes have been found in these patients.
Therapy
Surgical intervention is based on ligation or occlusion of the internal spermatic veins. Ligation is performed at different levels:
- Inguinal (or subinguinal) microsurgical ligation
- Suprainguinal ligation, using open or laparoscopic techniques
The advantage of the former is the lower invasiveness of the procedure, while the advantage of the latter is a considerably lower number of veins to be ligated and safety of the incidental division of the internal spermatic artery at the suprainguinal level.
For surgical ligation, some form of optical magnification (microscopic or laparoscopic magnification) should be used because the internal spermatic artery is 0.5 mm in diameter at the level of the internal ring. The recurrence rate is usually less than 10%. Angiographic occlusion is based on retrograde or antegrade sclerotization of the internal spermatic veins.
Lymphatic-sparing varicocelectomy is preferred to prevent hydrocele formation and testicular hypertrophy development and to achieve a better testicular function according to the LHRH stimulation test (Level of evidence: 2; Grade of recommendation: A). The methods of choice are subinguinal or inguinal microsurgical (microscopic) repairs, or suprainguinal open or laparoscopic lymphatic-sparing repairs.
Angiographic occlusion of the internal spermatic veins also meets these requirements. However, although this method is less invasive, it appears to have a higher failure rate (Level of evidence: 2; Grade of recommendation: B).
There is no evidence that treatment of varicocele at paediatric age will offer a better andrological outcome than an operation performed later. The recommended indication criteria for varicocelectomy in children and adolescents are:
- Varicocele associated with a small testis
- Additional testicular condition affecting fertility
- Bilateral palpable varicocele
- Pathological sperm quality (in older adolescents)
- Varicocele associated with a supranormal response to LHRH stimulation test
- Symptomatic varicocele
Repair of a large varicocele physically or psychologically causing discomfort may be also considered. Other varicoceles should be followed-up until a reliable sperm analysis can be performed (Level of evidence: 4; Grade of recommendation: C).
Definitions:
Levels of Evidence
1a Evidence obtained from meta-analysis of randomized trials
1b Evidence obtained from at least one randomized trial
2a Evidence obtained from at least one well-designed controlled study without randomization
2b Evidence obtained from at least one other type of well-designed quasi-experimental study
3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
Grades of Recommendation
- Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
- Based on well-conducted clinical studies, but without randomized clinical studies
- Made despite the absence of directly applicable clinical studies of good quality
