AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Reference to enlarged scrotal veins in teenagers occurred as early as 1885. Barwell observed ipsilateral testicular volume loss associated with varicocele and catch-up growth following surgery. Four years later, Bennett commented on his observation of a change in the character of seminal fluid following ligation of a varicocele.

During this century, considerable debate regarding the etiology and effects of varicoceles has appeared in the literature. However, the direct relationship between varicoceles and testicular atrophy, changes in Leydig and Sertoli cell function, abnormal seminal parameters, and endocrine abnormalities is now well established. In the past 30 years, the advent of interventional radiology and minimally invasive surgical techniques has affected the way physicians approach adolescent varicocele.

Presentation

Patients are commonly referred after a soft mass in the scrotum or a difference in size of the testicles is detected during a well-child visit or sports physical. Most varicoceles are asymptomatic, but testicular pain or a mass that is concerning to the patient or parent may, on occasion, be presenting symptoms. Although varicoceles may be bilateral, they are usually unilateral and almost always left-sided. A unilateral right-sided 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-sided varicocele. These patients must undergo radiographic studies as part of their evaluation. Situs inversus is another etiology of a right-sided varicocele.

History of the Procedure

Symptoms of scrotal discomfort, a soft mass in the scrotum, or a difference in size of the testicles should alert the physician to perform a thorough examination to exclude a varicocele. Generally, adolescent varicoceles are asymptomatic.

Problem

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.

Frequency

Varicoceles are very rare in patients younger than 9 years, although 16% of adolescents and 15-20% of adult males have varicoceles. They are cited as one of the leading causes of male factor infertility and are detected in 35% of adult males with primary 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 are left-sided. These 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: 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-sided varicocele may be observed in association with a left varicocele (bilateral varicoceles), but an isolated right 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-sided varicocele. Situs inversus is another etiology of a right varicocele.

Pathophysiology

A varicocele is the most common correctable cause of male infertility.

Often, the ipsilateral testis is abnormally small. 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 mechanisms for this pathophysiology 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 catch-up growth of the adolescent testicle is observed following varicocele ligation.

Clinical

Most patients with adolescent varicoceles are asymptomatic, and varicocele is diagnosed based on palpation of the scrotum during a thorough upright physical examination. The patient should be examined in the standing position, and the scrotum should be visually inspected for distended veins. 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 varicocele has been said to feel like a bag of worms. The physician should then perform a Valsalva maneuver, which distends the veins in a patient with a varicocele. 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. 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 the table below). Most investigators use a standard orchidometer (ie, Prader orchidometer) to assess volume. Others suggest ultrasonography is a more accurate method of measurement. However, the added cost may be difficult to justify.

Average Male Testis Volume at Different Stages of Development, As Determined by Orchidometer

Adapted from Curr Urol Rep. 2002;100.

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

Varicoceles are graded based on physical examination findings and are classified as follows:

• Grade 0 - Subclinical varicocele; cannot be detected on physical examination; generally identified with ultrasonographic study 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 et al noted that testis volume was reduced by 81% in patients with grade 3 varicoceles and by 34% in patients with grade 2 varicoceles. 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. Some evidence shows that larger (grade 3) varicoceles may also place the contralateral right testis at risk for atrophy.

INDICATIONS

Section 3 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

To date, no strict criteria indicate which physical findings or diagnostic criteria absolutely necessitate surgical intervention in adolescents. 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.

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

• Varicocele associated with decreased ipsilateral testicular size: Generally accepted indication for correction is an orchidometer or ultrasound 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.

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

RELEVANT ANATOMY

Section 4 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

A varicocele is situated in the upper scrotum, above the testis. The spermatic cord extends upwards into the inguinal region, above the scrotum. The spermatic cord contains the spermatic veins; the vas; 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 risk of testis atrophy resulting from future vasectomy.

CONTRAINDICATIONS

Section 5 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

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 with prior 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.

WORKUP

Section 6 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Lab Studies

• No specific laboratory studies have proven 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.

Imaging Studies

• Accurate assessment of testicular volume is important to determine the necessity of surgical intervention. For assessment of testicular volume, ultrasonography is generally felt to be superior to orchidometer measurement. The testis is imaged in 3 dimensions, and the volume is calculated using the formula for an ellipse (volume = length X width X depth X 0.53).
• Upright Doppler ultrasonography 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 ultrasonography may also detect a small contralateral varicocele.
• CT scanning is rarely indicated but may exclude an obstructive etiology for an isolated right-sided 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 it has a limited role in adolescents. Teenagers with unexplained testicular atrophy or scrotal pain may be evaluated with venography but only if findings on an upright scrotal ultrasound with Doppler flow measurements during Valsalva maneuver are nondiagnostic.

Other Tests

• While not routinely performed in adolescents, a semen analysis in older teenagers may be appropriate when results may alter management decisions.

Diagnostic Procedures

• No procedures are used in the evaluation of varicoceles in adolescents.

Histologic Findings

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

TREATMENT

Section 7 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Medical therapy

No known medical therapy is available.

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 currently used.

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.

Preoperative details

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

Intraoperative details

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.

Postoperative details

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. The patient may return to school or work in 2-3 days.

Follow-up

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

Section 8 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Hydrocele formation is the most common complication. 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 carries a slightly higher risk.

Less common complications include testicular atrophy, hematoma, injury to the vas deferens, and recurrence.

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

OUTCOME AND PROGNOSIS

Section 9 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

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

Numerous studies have shown improved semen parameters and increased testicular volume following varicocele ligation in adolescents. Data on subsequent fertility rates in adolescents are lacking; however, prospective studies involving infertile adults have shown significantly improved pregnancy rates.

FUTURE AND CONTROVERSIES

Section 10 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

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.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

• Ando S, Giacchetto C, Beraldi E, et al. Progesterone, 17-OH-progesterone, androstenedione and testosterone plasma levels in spermatic venous blood of normal men and varicocele patients. Horm Metab Res. Feb 1985;17(2):99-103. [Medline].
• Atassi O, Kass EJ, Steinert BW. Testicular growth after successful varicocele correction in adolescents: comparison of artery sparing techniques with the Palomo procedure. J Urol. Feb 1995;153(2):482-3. [Medline].
• Belloli G, D'Agostino S, Musi L, Campobasso P. Adolescent varicocele: operative anatomy and tricks for successful correction. Eur J Pediatr Surg. Aug 1995;5(4):219-21. [Medline].
• Braedel HU, Steffens J, Ziegler M, et al. A possible ontogenic etiology for idiopathic left varicocele. J Urol. Jan 1994;151(1):62-6. [Medline].
• Buch JP, Cromie WJ. Evaluation and treatment of the preadolescent varicocele. Urol Clin North Am. Feb 1985;12(1):3-12. [Medline].
• Costabile RA, Skoog S, Radowich M. Testicular volume assessment in the adolescent with a varicocele. J Urol. May 1992;147(5):1348-50. [Medline].
• Fideleff HL, Boquete H, Ruibal G, et al. Varicocele in prepubertal boys. Evaluation of clinical Doppler and hormonal findings. Medicina (B Aires). 1996;56(6):679-82. [Medline].
• Gershbein AB, Horowitz M, Glassberg KI. The adolescent varicocele I: left testicular hypertrophy following varicocelectomy. J Urol. Oct 1999;162(4):1447-9. [Medline].
• Gorelick JI, Goldstein M. Loss of fertility in men with varicocele. Fertil Steril. Mar 1993;59(3):613-6. [Medline].
• Haans LC, Laven JS, Mali WP, et al. Testis volumes, semen quality, and hormonal patterns in adolescents with and without a varicocele. Fertil Steril. Oct 1991;56(4):731-6. [Medline].
• Hadziselimovic F, Herzog B, Jenny P. The chance for fertility in adolescent boys after corrective surgery for varicocele. J Urol. Aug 1995;154(2 Pt 2):731-3. [Medline].
• Hassan JM, Adams MC, Pope JC, et al. Hydrocele formation following laparoscopic varicocelectomy. J Urol. Mar 2006;175(3 Pt 1):1076-9. [Medline].
• Iselin CE, Almagbaly U, Borst F, et al. Safety and efficiency of laparoscopic varicocelectomy in one hundred consecutive cases. Urol Int. 1997;58(4):213-7. [Medline].
• Jones MA, Sharp GH, Trainer TD. The adolescent varicocele. A histopathologic study of 13 testicular biopsies. Am J Clin Pathol. Mar 1988;89(3):321-8. [Medline].
• Kass EJ, Freitas JE, Bour JB. Adolescent varicocele: objective indications for treatment. J Urol. Aug 1989;142(2 Pt 2):579-82; discussion 603-5. [Medline].
• Kass EJ, Belman AB. Reversal of testicular growth failure by varicocele ligation. J Urol. Mar 1987;137(3):475-6. [Medline].
• Kass EJ, Freitas JE, Salisz JA, Steinert BW. Pituitary gonadal dysfunction in adolescents with varicocele. Urology. Aug 1993;42(2):179-81. [Medline].
• Kass EJ, Marcol B. Results of varicocele surgery in adolescents: a comparison of techniques. J Urol. Aug 1992;148(2 Pt 2):694-6. [Medline].
• Kass EJ. The adolescent varicocele: treatment and outcome. Curr Urol Rep. Apr 2002;3(2):100-6. [Medline].
• Laven JS, Haans LC, Mali WP, et al. Effects of varicocele treatment in adolescents: a randomized study. Fertil Steril. Oct 1992;58(4):756-62. [Medline].
• Lemack GE, Uzzo RG, Schlegel PN, Goldstein M. Microsurgical repair of the adolescent varicocele. J Urol. Jul 1998;160(1):179-81. [Medline].
• Lenzi A, Gandini L, Bagolan P, et al. Sperm parameters after early left varicocele treatment. Fertil Steril. Feb 1998;69(2):347-9. [Medline].
• Lund L, Tang YC, Roebuck D, et al. Testicular catch-up growth after varicocele correction in adolescents. Pediatr Surg Int. 1999;15(3-4):234-7. [Medline].
• Lyon RP, Marshall S, Scott MP. Varicocele in youth. West J Med. Jun 1983;138(6):832-4. [Medline]. [Full Text].
• Mottrie AM, Matani Y, Baert J, et al. Antegrade scrotal sclerotherapy for the treatment of varicocele in childhood and adolescence. Br J Urol. Jul 1995;76(1):21-4. [Medline].
• Okuyama A, Nakamura M, Namiki M, et al. Surgical repair of varicocele at puberty: preventive treatment for fertility improvement. J Urol. Mar 1988;139(3):562-4. [Medline].
• Osuna JA, Lozano JR, Cruz I, Tortolero I. Pituitary and testicular function in adolescents with varicocele. Arch Androl. Nov-Dec 1999;43(3):183-8. [Medline].
• Paduch DA, Niedzielski J. Semen analysis in young men with varicocele: preliminary study. J Urol. Aug 1996;156(2 Pt 2):788-90. [Medline].
• Paduch DA, Niedzielski J. Repair versus observation in adolescent varicocele: a prospective study. J Urol. Sep 1997;158(3 Pt 2):1128-32. [Medline].
• Parrott TS, Hewatt L. Ligation of the testicular artery and vein in adolescent varicocele. J Urol. Aug 1994;152(2 Pt 2):791-3; discussion 793. [Medline].
• Pini Prato A, MacKinlay GA. Is the laparoscopic Palomo procedure for pediatric varicocele safe and effective? Nine years of unicentric experience. Surg Endosc. Apr 2006;20(4):660-4. [Medline].
• Pinto KJ, Kroovand RL, Jarow JP. Varicocele related testicular atrophy and its predictive effect upon fertility. J Urol. Aug 1994;152(2 Pt 2):788-90. [Medline].
• Podesta ML, Gottlieb S, Medel R Jr, et al. Hormonal parameters and testicular volume in children and adolescents with unilateral varicocele: preoperative and postoperative findings. J Urol. Aug 1994;152(2 Pt 2):794-7; discussion 798. [Medline].
• Reyes BL, Trerotola SO, Venbrux AC, et al. Percutaneous embolotherapy of adolescent varicocele: results and long-term follow-up. J Vasc Interv Radiol. Jan-Feb 1994;5(1):131-4. [Medline].
• Sayfan J, Siplovich L, Koltun L, Benyamin N. Varicocele treatment in pubertal boys prevents testicular growth arrest. J Urol. Apr 1997;157(4):1456-7. [Medline].
• Senbanjo RO, Lawani J, Nkposong EO. Changes in seminal quality following varicocelectomy in infertile Nigerian males. Afr J Med Med Sci. Sep-Oct 1986;15(3-4):63-71. [Medline].
• Sigman M, Jarow JP. Ipsilateral testicular hypotrophy is associated with decreased sperm counts in infertile men with varicoceles. J Urol. Aug 1997;158(2):605-7. [Medline].
• Skoog SJ, Roberts KP, Goldstein M, Pryor JL. The adolescent varicocele: what''s new with an old problem in young patients?. Pediatrics. Jul 1997;100(1):112-21. [Medline].
• Steeno O, Knops J, Declerck L, et al. Prevention of fertility disorders by detection and treatment of varicocele at school and college age. Andrologia. 1976;8(1):47-53. [Medline].
• Tauber R, Johnsen N. Antegrade scrotal sclerotherapy for the treatment of varicocele: technique and late results. J Urol. Feb 1994;151(2):386-90. [Medline].
• Ulker V, Garibyan H, Kurth KH. Comparison of inguinal and laparoscopic approaches in the treatment of varicocele. Int Urol Nephrol. 1997;29(1):71-7. [Medline].
• Vereecken RL, Boeckx G. Does fertility improvement after varicocele treatment justify preventive treatment at puberty?. Urology. Aug 1986;28(2):122-6. [Medline].
• Yamamoto M, Hibi H, Katsuno S, Miyake K. Effects of varicocelectomy on testis volume and semen parameters in adolescents: a randomized prospective study. Nagoya J Med Sci. Dec 1995;58(3-4):127-32. [Medline].

Article Last Updated: Dec 13, 2006