Varicocele in Adolescents Treatment & Management

No known medical therapy is available for varicocele. Watchful management may be an option with yearly check-ups and reevaluation of testis size.

Surgical ligation of the spermatic veins is the procedure used. Several methods are used, differing primarily in the level at which the vessels are approached. These include abdominal retroperitoneal (Palomo), inguinal (Ivanissevitch), and subinguinal approaches. Microsurgical techniques and laparoscopic-assisted transperitoneal or retroperitoneal approaches are also currently used.^{[4, 5]}

Interventional venography has also been used for transcatheter occlusion of the spermatic veins. This is accomplished by percutaneous embolization of the testicular veins, identified using transfemoral venography. Embolization materials include balloons, coils, and dextrose.

A thorough history and physical examination with attention to past surgical procedures is necessary to choose the best approach for ligation.

The aim of varicocele surgery is to identify and ligate the ascending venous network that drains the testis, epididymis, and vas deferens. The testicular artery is generally spared using a microscope with the inguinal approach. The artery and any branches are identified with direct visualization with administration of papaverine or lidocaine directly onto the vessels or with a Doppler probe. With the transperitoneal or retroperitoneal method, the internal spermatic artery is also usually divided in addition to the veins. Ligation of the internal spermatic artery in the retroperitoneum does not usually cause testicular atrophy because of the generous collateral circulation to the testicle.

Subinguinal approach

The incision is made over the external ring. Dilated cremasteric veins are ligated, and the spermatic cord is opened. The spermatic veins in the pampiniform plexus are separated and ligated, as are any dilated veins that accompany the vas deferens.

Microscopic subinguinal approach

The incision is made over the external ring, and the operating microscope is used to dissect out and preserve the testicular arteries and lymphatic vessels. Additionally, some authors advocate the additional step of delivering the testicle into the wound and performing ligation of the external spermatic and gubernacular veins.

Inguinal approach

The incision is made over the course of the inguinal canal, along with ligation of cremasteric, deferential, and spermatic veins with artery preservation. A microscope may be used with approach, as well.

Retroperitoneal approach

This approach consists of high ligation of the entire spermatic pedicle, approached with a low abdominal incision above the internal inguinal ring. This may also be performed as a testicular artery sparing procedure by opening the spermatic fascia to identify and preserve the artery.

Laparoscopic-assisted retroperitoneal approach

The internal inguinal ring, where the vas deferens joins the spermatic cord, is identified. The scrotum is compressed to dilate the spermatic veins. An incision is made in the peritoneum over the spermatic cord, and dissection is used to mobilize the cord vessels. Lymphatic vessels are dissected off of the spermatic cord, and the remaining artery and veins are clipped, tied, or cauterized and may be divided. The artery may be spared, with division of the spermatic veins, but this lengthens the procedure and may increase the risk of varicocele recurrence.

Varicocele ligation is an outpatient procedure. The patient is advised to expect postoperative wound and scrotal discomfort and possibly edema and ecchymosis. Proper wound care instructions are provided and oral analgesics prescribed. Icing and elevation of the scrotum may help reduce painful swelling. The patient may return to school or work in 2-3 days.

Routine postoperative visits for wound and testicular assessment are standard. In the first year, testicular volume and scrotal texture are periodically assessed to ensure that testicular atrophy, recurrence of the varicocele, or hydrocele formation has not occurred.

For excellent patient education resources, visit eMedicine's Men's Health Center. Also, see eMedicine's patient education articles Understanding the Male Anatomy and Testicular Pain.

Complications of varicocelectomy, regardless of the technique used, include hydrocele formation, recurrent or persistence of the varicocele, and, uncommonly, testicular atrophy.^[6] Hydrocele formation is the most common complication and most likely results from lymphatic obstruction. Frequency varies with the surgical method used. The microscopic-assisted procedures carry the lowest complication rates (< 1%). Inguinal, retroperitoneal, and laparoscopic ligations carry a postoperative hydrocele risk of less than 10%; embolization is very infrequently associated with hydrocele formation.

Table 2. Postoperative Complication Rates^[7] (Open Table in a new window)

Less common complications include testicular atrophy, hematoma, injury to the vas deferens, chronic testicular pain, and recurrence or persistence of the varicocele. Percutaneous embolization carries the unique, yet infrequent, risks of contrast reactions, puncture of the femoral artery, hemorrhage, extravasation, and migration of embolization balloons.

Recurrence rates following varicocele ligation vary with the technique used. Microsurgical approaches recur in fewer than 5% of cases, whereas a 13-16% rate is observed with inguinal, retroperitoneal, and laparoscopic ligations. Embolization has an 80-90% success rate and a recurrence rate of approximately 10-25%.

The purported benefits of varicocele ligation include improved semen parameters and increased testicular volume. Kass and Belman were the first to demonstrate a significant increase in testicular volume after varicocele repair in adolescents.^[8] However, note that testicular catch-up growth occurs in a significant proportion of adolescents who are managed conservatively with close follow-up. A period of observation prior to proceeding with surgery is justified, even in those patients with a significant discrepancy in testicular size (ie, >20%).

In addition to an increase in testicular size, other studies have shown that varicocelectomy improves not only sperm motility, density, and morphology but also specific functional sperm defects.

A meta-analysis of 22 studies with 2989 patients who underwent varicocele repair showed that 71% of patients had improvements in their postoperative semen parameters, and 37% achieved pregnancy.^[9] However, controversy still surrounds whether varicocelectomy improves pregnancy rates. In a large controlled study, no significant difference in pregnancy rates (25.2% in the treatment group versus 27.1% in the counseling group) was noted at 1 year follow-up. Nevertheless, sperm concentration did significantly increase in the treated patients, whereas no significant changes in semen parameters occurred in the nontreatment group.

Further research may provide a method to adequately assess which adolescents with varicoceles are at a significant risk for infertility, thus warranting intervention. This would resolve present controversies as to relative versus absolute indications for surgery.

Modifications and improvements in surgical techniques are ongoing, and lower recurrence and complication rates are likely to result.

Finally, better understanding of the impact of a varicocele on the germinal epithelium of the testis may provide alternative management options.