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:
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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.
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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
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Low oxygen content in the dilated veins may result in local tissue hypoxia; this could affect both testicular architecture and sperm production
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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:
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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
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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
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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
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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.
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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% |
