Varicocele in Adolescents

Updated: Sep 22, 2022

Author: James M Elmore, MD; Chief Editor: Marc Cendron, MD

Overview

Practice Essentials

References to dilated and tortuous veins of the spermatic cord, now referred to as a varicocele, occurred as early as 1885. Even at that time, varicoceles were known to be associated with ipsilateral testicular atrophy, which appeared to be reversible after ligation. Four years later Bennett commented on his observation of a change in the character of seminal fluid after ligation of a varicocele.

Since these reports, considerable debate regarding the etiology and effects of varicoceles has appeared in the literature. The direct relation between varicoceles and testicular atrophy, changes in Leydig and Sertoli cell function, abnormal seminal parameters, and endocrine abnormalities has been studied. Over the past few decades, the advent of interventional radiology and minimally invasive surgical techniques has affected the way in which physicians approach adolescent varicocele.

Varicoceles usually become evident around adolescence[1, 2] and are rarely reported to arise in older men. Patients are commonly referred to the urologist either after detection of a scrotal mass, classically described as a "bag of worms," or after detection of a difference in testicle size during a well-child visit or sports physical. Most varicoceles are asymptomatic; however, testicular pain or a mass may be a presenting symptom.

Although varicoceles may be bilateral, they are usually unilateral and almost always on the left side. A unilateral right-side varicocele should prompt an investigation for a retroperitoneal process such as a mass that causes obstruction of the right internal spermatic vein. Thrombosis or occlusion of the inferior vena cava must be ruled out in all patients who present with a solitary right-side varicocele. These patients should undergo radiographic studies (eg, computed tomography [CT]) as part of evaluation. Situs inversus is another cause of a right-side varicocele.

Moderate evidence supports the view that varicocele treatment results in improvement of testicular volume and sperm concentration. No known medical therapy is available. Surgical ligation of the spermatic veins is the procedure used. To date, the physical findings or diagnostic criteria that dictate surgical intervention in adolescents have not been strictly defined. Each case is handled individually, with a discussion among the patient, parents, and physician regarding the risks of intervention and potential impact on future fertility. Interventional venography has also been used for transcatheter occlusion of the spermatic veins.

For patient education resources, see the Men's Health Center, as well as The Male Anatomy and Testicular Pain.

Anatomy

As with the arterial supply to the testis, the venous drainage has multiple anastomoses in the scrotum and the inguinal canal, which are referred to as the pampiniform plexus. A varicocele results from an abnormal dilation of this venous network.

A varicocele is an abnormal dilation of the pampiniform plexus of the testicular veins, which drain the testicle. Initial presentation usually occurs during puberty, with incidence in 13-year-old adolescent boys equal to that of adult men (15%). Rarely, varicoceles are noted in the prepubertal period.

A varicocele is situated in the upper scrotum, above the testis. The spermatic cord extends upward into the inguinal region, above the scrotum. It contains the spermatic veins, the vas deferens, and the testicular arteries, including the internal spermatic artery (may be multiple branches), the vasal artery, and the external spermatic artery. Above the inguinal region, the vas, with its arterial supply, diverges from the internal spermatic artery and veins, which course through the retroperitoneum, along the psoas muscle.

Corrective surgery involves interrupting the refluxing spermatic veins. This may be performed at various levels, usually above the varicocele. Surgery on the varicocele itself is generally avoided because of the many venous branches and the increased risk of bleeding.

Surgery may be performed at the level of the uppermost scrotum, the inguinal area, or the retroperitoneum. When surgery is performed in the retroperitoneum, some authors advocate dividing both the testicular artery and the veins to avoid missing any venous branches. This latter technique relies on the vasal artery as the only remaining blood supply to the testis. These patients should be warned of the potential for testicular atrophy resulting from future vasectomy.

Pathophysiology

Often, in the presence of a varicocele, the ipsilateral testis is abnormally small as compared with the contralateral testis. Histologic studies have revealed seminiferous tubule sclerosis, small vessel degenerative changes, and abnormalities of Leydig, Sertoli, and germ cells.

These changes have been documented in patients as young as 12 years. Effects of a varicocele on semen parameters have been extensively studied in adults. Consistent findings have included decreased sperm motility, lower total sperm counts, and increased number of abnormal sperm forms. A limited number of studies in adolescents with varicoceles have also shown altered seminal parameters in this age group.

Reasons for altered sperm production, testicular size, and morphologic changes are not clearly understood. Proposed pathophysiologic mechanisms include the following:

Dilated veins with pooling of venous blood results in increased scrotal and testicular temperature; this is theorized to alter DNA synthesis within the testicle, leading to morphologic changes in sperm and testicular tissue.
Renal and adrenal metabolites that reflux into dilated spermatic veins affect testicular tissue damage through undefined mechanisms; testicular hormone function may be compromised, leading to impaired spermatogenesis
Low oxygen content in the dilated veins may result in local tissue hypoxia; this could affect both testicular architecture and sperm production
Paracrine imbalances in the testicle due to any of the above mechanisms may lead to impaired testicular function

These findings may be reversed with corrective surgery, and catchup growth of the adolescent testicle is observed after varicocele ligation. In adults, varicocele is felt to be the most correctable cause of infertility.

Etiology

The etiology of this condition is unknown but likely multifactorial. Various theories have been proposed to explain the cause of a varicocele in light of the fact that 90% of all varicoceles occur on the left side. These theories include the following:

Congenital absence of the valves in the left testicular vein, which normally prevent retrograde flow of blood in the upright position - Anomalous branches may also bypass the valves
Abnormal variations in venous drainage of the testes - An asymmetrical pattern is usually present, with the right testicular vein draining directly into the inferior vena cava and the left testicular vein inserting at a right angle into the left renal vein; this pattern predisposes to slower drainage in the left testicular vein
The "nutcracker" phenomenon ^[3]- The left renal vein is occasionally compressed between the superior mesenteric artery and the aorta; this creates higher pressure in the left testicular vein, which drains into the renal vein
Increased length of the left testicular vein - The left vein is 8-10 cm longer than the right testicular vein

A right-side varicocele may be observed in association with a left-side varicocele (bilateral varicoceles), but an isolated right-side varicocele is very rare and raises certain concerns. The possibility of thrombosis or occlusion of the inferior vena cava must be eliminated in all patients who present with a solitary right-side varicocele or in older adults who present with new-onset varicoceles.

Epidemiology

Varicoceles are extremely rare in patients younger than 9 years. The prevalence of varicoceles in individuals aged 10-19 years is reported to be approximately 15% and is similar to the prevalence reported for adults. However, because most adolescent varicoceles are asymptomatic, the true incidence of adolescent varicoceles is likely higher.

Varicoceles are cited as one of the leading causes of adult male factor infertility and are detected in 35% of adult males with primary infertility. Some studies have noted that adolescent varicoceles are more commonly found in normal and underweight children than in obese children.[4, 5]

Prognosis

Recurrence rates following varicocele ligation vary according to the technique used. With microsurgical approaches, varicoceles recur in fewer than 5% of cases, whereas a 13-16% rate is observed with inguinal, retroperitoneal, and laparoscopic ligations. Embolization has a success rate of 80-90% 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.[6] However, it should be noted that testicular catchup growth occurs in a significant proportion of adolescents who are managed conservatively with close follow-up.

A period of observation before proceeding with surgery is justified, even in those patients with a significant (ie, >20%) discrepancy in testicular size. Although testicular catchup growth does tend to occur with an initial size discrepancy of less than 20%, testicular volume and semen parameters have not been shown to be significantly different between conservatively managed and surgically treated groups.[7]

Sparing of the testicular artery was previously felt to be beneficial in aiding catchup growth. Fast et al observed that the rate of persistent or recurrent varicocele was increased (though not significantly so) in the patients treated with artery-sparing varicocelectomy (12.2% vs 5.4%), and they found no difference in catchup growth.[8]

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 for adult subfertility showed that 71% of patients had improvements in their postoperative semen parameters, and 37% achieved pregnancy.[9] However, controversy still surrounds the question of whether varicocelectomy improves pregnancy rates in this patient population.

In a large controlled study, no significant difference in pregnancy rates (25.2% in the treatment group vs 27.1% in the counseling group) was noted at 1-year follow-up. Nevertheless, sperm concentration did increase significantly in the treated patients, whereas no significant changes in semen parameters occurred in the nontreatment group.

The effect of varicocelectomy on semen parameters and pregnancy rates in adolescents has yet to be determined conclusively. However, Bogaert et al retrospectively identified patients treated with antegrade sclerotherapy or conservative management of adolescent varicocele and found no difference in paternity between the two groups at a mean of 17 years later.[10] This study had inherent unavoidable biases that may have skewed results; still, it underscores our lack of understanding of this condition in adolescence and its effect on future paternity.

A study by Sizonov et al evaluated paternity rates in 122 adult men who had been actively monitored for unilateral varicocele with ipsilateral testicular hypotrophy during childhood and adolescence but had not undergone varicocelectomy.[11] They found a high (91.5%) paternity frequency in the surveyed group.

Presentation

History and Physical Examination

The vast majority of adolescents with varicoceles are asymptomatic. The diagnosis is made by carefully palpating the scrotum during a thorough upright physical examination. The patient is examined in the standing position, and the scrotum is visually inspected for distended veins, which can usually be seen on the lateral aspect of the scrotum. The testes, spermatic cord, and scrotum are palpated, and testicular size is assessed with an orchidometer. A small varicocele may feel like a thickened spermatic cord; a larger one has been said to feel like a bag of worms.

The physician should then ask the patient to perform a Valsalva maneuver, which distends the veins of the pampiniform plexus and accentuates physical findings. This is a necessary adjunct, albeit one that is often omitted in the primary care setting, for helping the clinician detect subtle changes in the pampiniform plexus that can facilitate the diagnosis of a varicocele.[12]

Next, examine the patient in a supine position. The venous dilation of the varicocele should diminish. Consider an obstructive etiology if this does not occur.

The testes of a normal patient should be symmetrical in size and consistency. The orchidometer can be a reliable method of assessing testicular size, with good interobserver variability[13] ; however, compared with ultrasonography (US), it may be inaccurate in distinguishing a testis volume differential of less than 50%.[14]

Two formulas are used to calculate testicular volume on the basis of dimensions obtained via US: the Lambert formula and the volume-of-rotational-ellipsoid formula. The Lambert formula is as follows:

Testicular volume = Length × width × depth × 0.71

Two variations exist for the volume-of-rotational-ellipsoid formula:

Testicular volume = Length × width × depth × 0.52
Testicular volume = Length × width ² × 0.52

Hsieh et al studied the reliability of these formulas and found that the Lambert formula was more accurate than either volume-of-rotational-ellipsoid formula and more precise than the second of the two volume-of-rotational-ellipsoid formulas.[15]

A size difference of more than 3 cm3 is considered significant. The average volume of the male testis is 23 ± 3 cm3, and standardized tables show the reference ranges for appropriate testis volume at different stages of development (see Table 1 below).[16]

Table 1. Average Male Testis Volume at Different Stages of Development, as Determined by Orchidometer^[16] (Open Table in a new window)

Tanner Stage	Left Testis	Right Testis
1	4.76 ± 2.76 cm3	5.20 ± 3.86 cm3
2	6.40 ± 3.16 cm3	7.08 ± 3.89 cm3
3	14.58 ± 6.54 cm3	14.77 ± 6.1 cm3
4	19.80 ± 6.17 cm3	20.45 ± 6.79 cm3
5	28.31 ± 8.52 cm3	30.25 ± 9.64 cm3

Other presentations of varicoceles include symptoms of acute or chronic scrotal discomfort, differing testicular sizes without a palpable varicocele on recumbent physical examination, and incidental finding on scrotal US.

Classification

Varicoceles are graded on the basis of physical examination findings and are classified as described by Dubin and Amelar[17] :

Grade 0 - Subclinical varicocele; cannot be detected during physical examination; generally identified with US or venography
Grade 1 - Detected with palpation with difficulty (< 1 cm); increase in size with Valsalva maneuver
Grade 2 - Easily detected without Valsalva maneuver (1-2 cm)
Grade 3 - Detected visually at a distance (>2 cm)

Multiple investigators have directly correlated the degree of testicular atrophy with varicocele grade. Steeno noted that testis volume was reduced by 81% in patients with grade 3 varicoceles and by 34% in patients with grade 2 varicoceles.[18] No patients with grade 1 varicoceles were noted to have testicular atrophy.

Lyon et al reported that 77% of adolescent boys with easily palpable varicoceles had testis growth arrest, further suggesting that larger varicoceles are more likely to be associated with growth arrest.[19] Some evidence shows that larger (grade 3) varicoceles may also place the contralateral right testis at risk for atrophy.

Workup

Laboratory Studies

No specific laboratory studies have proved useful in the evaluation of an adolescent with a varicocele. Levels of basal serum testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) are not altered in the patient with varicocele.

Gonadotropin-releasing hormone (GnRH) stimulation tests are advocated at some centers. Adolescents at Tanner stage 4 and 5 with large varicoceles tend to have an exaggerated LH and FSH response to GnRH administration, but this is not a consistent finding. Some authors believe that this represents early testicular dysfunction and is an indication for surgical repair, though this has not been prospectively studied.

Semen analysis has not been widely used as a clinical decision-making tool in adolescent patients in the United States, because of the unavailability of well-defined semen parameters for this age group. Several groups have studied postvaricocelectomy changes in semen parameters, with mixed results. Semen analysis is more typically performed in adult patients, in whom baseline abnormalities can be an indication for surgical correction, with postoperative improvements in semen parameters expected. Various authors have advocated more widespread use of semen analysis in adolescents.[20, 21]

Imaging Studies

Accurate assessment of testicular volume is important in determining indications for surgical intervention. In the assessment of testicular volume, ultrasonography (US) is generally considered to be superior to orchidometer measurement. The testis is imaged in three dimensions, and the volume is calculated by using the formula of Lambert (volume = length × width × depth × 0.71).

Upright Doppler US with and without Valsalva maneuver may be used in cases in which a varicocele is suspected but not confirmed with physical examination findings, such as in an adolescent who is obese. Doppler US may also reveal a small contralateral varicocele. Color Doppler dynamic perfusion measurements of the testis parenchyma may help in assessing damage to the testis and the need for surgery.[22]

Computed tomography (CT) is rarely indicated but may exclude an obstructive etiology for an isolated right-side varicocele or one that does not diminish with the patient supine. Potential findings include a renal or other retroperitoneal mass or thrombosis of the inferior vena cava.

Venography is the study of choice to detect a subclinical varicocele in the evaluation of infertile adult patients but has a limited role in adolescents. Teenagers with unexplained testicular atrophy or scrotal pain may be evaluated with venography, but only if findings on upright scrotal US with Doppler flow measurements during the Valsalva maneuver are nondiagnostic.

Other Tests

Although not routinely performed in adolescents, a semen analysis may be appropriate in older teenagers; abnormal results may influence management decisions. However, one sperm count may not always be considered reliable, and normal sperm count parameters have not been published for adolescents.

Histologic Findings

Testicular biopsy to assess any damage to the testicle is not routinely performed. The data currently available provide no specific histologic criteria for predicting the reversibility of changes or the impact on fertility.

Treatment

Approach Considerations

Moderate evidence supports the view that varicocele treatment results in improvement of testicular volume and sperm concentration.[23, 24] To date, the physical findings or diagnostic criteria that dictate surgical intervention in adolescents have not been strictly defined.[25] Controversies and opinions regarding when to operate and on whom to operate abound. Each case is handled individually, with a discussion among the patient, parents, and physician regarding the risks of intervention and potential impact on future fertility.

Ipsilateral testicular growth retardation is the most frequent relative indication for varicocele repair in adolescents; the concern is that patients with varicocele and ipsilateral testicular growth retardation at that age may manifest impaired fertility in adulthood.

Although controversial, general guidelines used by the pediatric urologist to determine if surgery is indicated typically include the presence of one or more of the following:

Varicocele associated with decreased ipsilateral testicular size - A generally accepted indication for correction is an orchidometer or ultrasonography (US) measurement revealing a 20% volume deficit in the involved testis
Bilateral varicoceles
Symptomatic painful varicocele
Abnormal findings on semen analysis

Other disconcerting factors include grade 2 or 3 varicocele or significant difference in testicular consistency, with a softer ipsilateral testis.

The European Association of Urology (EAU) has published recommendations for management of varicocele in children and adolescents (see Guidelines).[26]

A 2019 review of childhood and adolescent varicocele from an endocrinologic perspective suggested the following[27] :

In patients with peak retrograde flow (PRF) less than 30 cm/s, testicular asymmetry less than 10%, and no evidence of sperm and hormonal abnormalities, conservative management may be considered
In patients with 10-20% testicular volume asymmetry or PRF greater than 30 cm/s but less than or equal to 38 cm/s or sperm abnormalities, careful follow-up may ensue
In the case of absent catchup growth or sperm recovery, varicocele repair should be proposed
In patients with painful varicocele, testicular volume asymmetry 20% or greater, PRF greater than 38 cm/s, infertility, and failure of testicular development, treatment can be proposed at the initial consultation

If the decision is made to defer surgery, the patient should be monitored every 6-12 months so that any deleterious effects can be detected as early as possible. The question of surgical intervention is readdressed at that time.

Varicocele ligation in a healthy patient has no specific contraindications, but various surgical approaches offer different advantages, and certain procedures should be avoided in specific settings. For example, a history of previous surgery may influence venous disruption within the site. With previous abdominal or retroperitoneal surgery, laparoscopic surgery is less desirable.

A history of inguinal surgery makes a second inguinal approach more difficult and potentially hazardous to the spermatic cord structures. Previous inguinal surgery may have also compromised the arterial supply of the testis.

For this reason, when an adolescent who has previously undergone inguinal hernia surgery develops a varicocele, the best technique involves an inguinal approach with microscopic magnification to optimally identify and preserve the testicular artery. A retroperitoneal approach with testicular artery ligation is contraindicated because the initial hernia surgery could have inadvertently injured the vasal artery, and high ligation of the internal spermatic artery may cause testis atrophy due to arterial insufficiency.

Further research may provide a method of adequately determining which adolescents with varicoceles are at significant risk for infertility and, thus, when intervention is warranted. 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.

Medical Therapy

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

Surgical Therapy

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 employed.[28, 29, 30]

In a comparison of subinguinal and high inguinal microsurgical techniques, Shiraishi et al found that the two approaches appear to have similar success rates with regard to testicular growth.[31] However, the high inguinal approach, which involves fewer divisions of veins and is associated with a larger diameter of the spermatic artery, is easier to perform.

Interventional venography has also been used for transcatheter occlusion of the spermatic veins. This is accomplished by percutaneous embolization of the testicular veins, identified by means of transfemoral venography. Embolization materials include balloons, coils,[32] and dextrose.

A systematic review and meta-analysis by Fabiani et al compared surgical ligation with sclero-embolization for treatment of varicocele in children, adolescents and adults.[33] There were no significant differences in in overall complications, wound infection, testis pain, surgical-site hematoma, total sperm count, sperm motility, pregnancy, or recurrence rate.

Operative details

The aim of varicocele surgery is to identify and ligate the ascending venous network that drains the testis, epididymis, and vas deferens. A thorough history and a careful physical examination, with particualr attention to past surgical procedures, are necessary to choose the best approach for ligation.

The testicular artery is generally spared with the use of a microscope in 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. Placing the operating table in a slight reverse Trendelenburg position may help dilate the internal spermatic veins, facilitating their identification during surgery.

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 spermatic cord is dissected into the operative field. The operating microscope is used to identify and ligate the internal spermatic veins. Care is taken to identify and preserve the testicular artery by using Doppler US or by visually identifying a pulsatile artery in the spermatic cord. Lymphatic vessels are also preserved when possible to prevent future hydrocele formation.

If the procedure is performed with local anesthesia and light sedation, the patient can perform a Valsalva maneuver to fill any remaining veins. Some authors advocate the additional step of delivering the testicle into the wound and performing ligation of the external spermatic and gubernacular veins. Division of the veins after ligation is optional.

Inguinal approach

The incision is made over the course of the inguinal canal, and the external inguinal ring is incised toward the internal inguinal ring. Care is taken to preserve the ilioinguinal nerve coursing under the external oblique aponeurosis. After the spermatic cord is delivered, the internal spermatid fascia is incised, and the branches of the internal spermatic vein are identified and separated from the gonadal artery with the help of Doppler US. The branches of the internal spermatic vein are ligated.

A microscope may be used with this approach as well. Again, division of the veins after ligation is optional.

Retroperitoneal approach

This approach consists of high ligation of the entire spermatic pedicle, approached via a low abdominal incision above the internal inguinal ring. A laparoscopic-assisted approach is recommended in obese patients because of the limited exposure obtained with an open approach. Care is taken to sweep the peritoneum from the spermatic vessels and to stay extraperitoneal. This operation 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

A camera port is placed along the lower portion of the umbilicus, along with a single 3- to 5-mm instrument port placed just laterally. 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 gonadal vessels approximately 4-5 cm proximal to the internal ring, and dissection is used to mobilize the cord vessels. (See the video below.) Lymphatic vessels are dissected off 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, increases the risk of varicocele recurrence, and has not been shown to impact catchup growth.[8]

Laparoscopic varicocelectomy.

Postoperative Care

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.

Complications

Varicocelectomy, regardless of the technique employed, carries a risk of complications. The complication rate varies with the surgical method used (see Table 2 below).[34] 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^[34] (Open Table in a new window)

Technique	Hydrocele	Recurrence or Failure
Open inguinal/sublingual	3-9%	15% average
Microscopic inguinal/sublingual	< 1%	1-3%
Retroperitoneal mass ligation	7.2%	2%
Retroperitoneal artery sparing	< 7.2%	11%
Laparoscopic	Similar to open	Similar to open
Embolization	None	10-25%

Hydrocele formation is the most common complication of varicocelectomy and most likely results from lymphatic obstruction.[35] An effort to spare lymphatics intraoperatively with the laparoscopic approach has been shown to result in lower hydrocele rates.[36]

Less common complications include testicular atrophy, hematoma, injury to the vas deferens, chronic testicular pain, and recurrence or persistence of the varicocele. Postoperative pain may be reducible with intraoperative administration of local anesthetics.[37]

Percutaneous embolization carries the unique, yet infrequent, risks of contrast reactions, puncture of the femoral artery, hemorrhage, extravasation, and migration of embolization balloons.

In a large multicenter analysis of complications and recurrence after treatment of varicocele in young (< 19 y) men, Lurvey et al found that the retreatment rate was significantly higher with percutaneous embolization than with either open or laparoscopic varicocelectomy and that open and laparoscopic varicocelectomy did not differ significantly from each other with regard to retreatment rate and hydrocele formation.[38]

Long-Term Monitoring

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.

Guidelines

EAU Guidelines for Pediatric Varicocele

In 2022, the European Society for Paediatric Urology (ESPU) published the following recommendations for management of varicocele in children and adolescents[26] :

Examine varicocele in the standing position and classify into three grades
Use scrotal ultrasonography (US) to detect venous reflux without Valsalva maneuver in the supine and upright position and to discriminate testicular hypoplasia
In all prepubertal boys with a varicocele and in all isolated right varicoceles, perform standard renal US to exclude a retroperitonal mass
Inform caregivers and patients and offer surgery for (1) varicocele associated with a persistent small testis (size difference > 2 mL or 20%), (2) varicocele associated with additional testicular condition affecting fertility (cryptorchidism, history of torsion, trauma), (3) varicocele associated with pathologic sperm quality (in older adolescents), or (4) symptomatic varicocele
Use some form of optical magnification (microscopic or laparoscopic) for surgical ligation
Use lymphatic-sparing varicocelectomy to prevent hydrocele formation and testicular hypertrophy

Author

James M Elmore, MD Clinical Assistant Professor, Department of Urology, Division of Pediatric Urology, Emory University/Children's Healthcare of Atlanta

James M Elmore, MD is a member of the following medical societies: Alpha Omega Alpha, American Urological Association, Societies for Pediatric Urology

Disclosure: Nothing to disclose.

Coauthor(s)

Michael L Garcia-Roig, MD Pediatric Urologist, Georgia Urology

Michael L Garcia-Roig, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Andrew J Kirsch, MD, FAAP, FACS Clinical Professor of Urology, Chief of Pediatric Urology, Emory University School of Medicine, Children's Healthcare of Atlanta; Partner, Georgia Urology, PA

Andrew J Kirsch, MD, FAAP, FACS is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, Society for Fetal Urology

Disclosure: Nothing to disclose.

Joseph Ortenberg, MD Clinical Professor of Urology and Pediatrics, Louisiana State University School of Medicine, New Orleans; Director of Urologic Education, Children's Hospital, New Orleans;

Joseph Ortenberg, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Plastic Surgeons, American Urological Association, Society of University Urologists

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Harry P Koo, MD Chairman of Urology Division, Director of Pediatric Urology, Professor of Surgery, Virginia Commonwealth University School of Medicine, Medical College of Virginia; Director of Urology, Children's Hospital of Richmond

Harry P Koo, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Urological Association

Disclosure: Nothing to disclose.

Chief Editor

Marc Cendron, MD Associate Professor of Surgery, Harvard School of Medicine; Consulting Staff, Department of Urological Surgery, Children's Hospital Boston

Marc Cendron, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, New Hampshire Medical Society, Societies for Pediatric Urology, Society for Fetal Urology, Johns Hopkins Medical and Surgical Association, European Society for Paediatric Urology

Disclosure: Nothing to disclose.

Additional Contributors

Bartley G Cilento, Jr, MD Instructor, Department of Surgery, Division of Urology, Children's Hospital of Boston and Harvard Medical School

Bartley G Cilento, Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, Massachusetts Medical Society

Disclosure: Nothing to disclose.

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