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.
-
Laparoscopic varicocelectomy.
Tables
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 |
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% |
