A 16-year-old male came to clinic for his health supervision visit. He was a wrestler who had had a shoulder strain and an auricular hematoma the previous season that were now resolved. He and his parents had no concerns. The review of systems was negative.
The pertinent physical exam showed a well-developed male with normal vital signs. Weight was in the 25% and length was in the 50%. Both were consistent with previous measurements. His examination was Tanner V for pubic hair and testicular size. His examination was normal except for a 2×2 cm “bag of worms” mass that was palpable in the upper scrotum that decreased when the patient was lying supine and increased when standing and performing a valsalva maneuver. The patient had been unaware of it and denied any pain. The testicles appeared to be the same size and no other masses or abnormalities were noted. The diagnosis of an asymptomatic varicocele was made. The physician discussed the varicocele with the family and originally was going to monitor it along with the family as it did not appear be causing any problems at the time. After reviewing a PUBMED search, the pediatrician talked with the family and referred the patient to a pediatric urologist for a more accurate testicular volume measurement and future monitoring.
Varicoceles are caused by high venous back pressure which causes a tortuous dilatation of the testicular veins (pampiniform plexus) of the spermatic cord. They occur more on the left than right because the left renal vein has a higher pressure than the inferior vena cava which drain the left and right gonadal veins respectively. Varicoceles are not very common in young children (3% in < 10 years old) but increase during the adolescent years when the incidence is ~15% which is similar to the adult population. Most varicoceles do not cause problems, but can. The most worrisome problem is male infertility. "It is estimated that 85% of men with varicocele will not encounter male factor infertility." However for those with male factor infertility, varicocele occurs in up to 40% of men. "In contrast, most adolescents who present with varicocele are asymptomatic and their fertility future is unknown." Therefore evaluation and management for adolescent males with asymptomatic varicocele is controversial.
Varicoceles should reduce in size when the patient is supine. If the varicocele does not reduce when supine, a pelvic/abdominal mass should be considered. Varicoceles are graded with the patient standing:
i. Palpable with valsalva
ii. Palpable at rest
iii. Grossly visible
Subclinical varicoceles are those that are found incidentally such as scrotal ultrasound. Subclinical varicoceles do not have an impact on fertility but can progress over time and may require long-term followup.
Some criteria for evaluation include:
- Scrotal pain or discomfort that is chronic and not improved by support
- Testicular volume loss or discrepancy – as assessed by orchiometer or ultrasound is important. Ultrasound is the most sensitive but orchiometer is less expensive.
Testicular volume loss or discrepancy is often the primary determinant of potential treatment.
- Additional urological problems
Evaluation can include initial and serial testicular volume measurement, semen analysis, and hormonal analysis. Indication for surgery, embolization or sclerotherapy treatment are also controversial with combinations of factors weighting the decision. One author states, “Varicocele treatment for infertility is not indicated in patients with either normal semen quality or a subclinical varicocele. Varicocele repair in adolescents should be considered when there is objective evidence of reduced ipsilateral testicular size.” Abnormal semen analysis or hormone levels also are factors in the decision making.
Questions for Further Discussion
1. What is included in the differential diagnosis of scrotal masses?
2. What are causes of testicular pain? A review can be found here.
3. Describe the differences between inguinal and femoral hernias?
- Disease: Varicocele | Testicular Disorders
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Specialty: Nephrology / Urology
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MedlinePlus for this topic: Testicular Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Garcia-Roig ML, Kirsch AJ. The dilemma of adolescent varicocele. Pediatr Surg Int. 2015 Jul;31(7):617-25.
Kolon TF. Evaluation and Management of the Adolescent Varicocele. J Urol. 2015 Nov;194(5):1194-201.
Casey JT, Misseri R. Adolescent Varicoceles and Infertility. Endocrinol Metab Clin North Am. 2015 Dec;44(4):835-42.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital