Urology ●
Five common urological problems
affecting adolescent men
Rebecca Tregunna, Senior Urology Fellow;1 Dan Wood, Consultant Urological Surgeon2
1. Eastbourne District General Hospital 2. The Institute of Urology, University College London Hospitals
Young men can be a
challenging group and may
resist engagement with
health care. It is important
that then when they do
attend their problem is
managed appropriately. This
paper gives a background
to five common adolescent
problems, including tips on
how to manage them.
Y oung men are less likely to see
a doctor than their female
counterparts,1 and the reasons
behind this are varied. However, it is
important that then when they do
attend, their problem is recognised,
diagnosed and they are given
appropriate advice and treatment.
This paper gives a background to
five common urological conditions,
focussing on elective/non-emergency
presentations. We have not sought
to tackle emergency presentations,
such as testicular torsion or
paraphimosis as these are covered
comprehensively elsewhere.
The foreskin
The natural history of the foreskin
is well documented, with 90%
becoming fully retractile by the age
of three years and, beyond that, data
suggest that only 1–2% will need
intervention (only 0.6% have an
absolute indication), although in an
English survey, rates of medical
circumcision were found to be 3.8%.2,3
Lichen sclerosis et atrophicus
remains the only absolute indication
wchh.onlinelibrary.wiley.com
for medical circumcision, and this
is rarely seen before five years of
age but may be seen in adolescents.
However, there is a group of
adolescents who find foreskin
retraction very uncomfortable,
particularly if their penis is erect.
When examined they can have a
short frenulum (this may be
shortened with scarring) or a tight
preputial band that catches on the
corona of the glans.
The vast majority of cases of
adolescent foreskins referred to a
specialist clinic are normal or need
minor (non-surgical) intervention, and
there are no published data for this
group. As a result, it is important to
develop a strategy on how to deal
with these patients. For example, it is
sensible to explain the natural history
of the foreskin, while examination
quickly reveals whether the foreskin
is being regularly retracted and
cleaning underneath is taking place.
This is the first piece of advice that
should be given: retraction each time
they pass urine and during every
bath/shower. The patient may also
wish to try a steroid cream, and
instructions for application are
important. The patient should use it
twice a day, every day for six weeks
and apply the cream specifically to
the affected area (ie, the tight band).
If all else fails a ‘Heineke Mikulicz-
type’ approach can be taken to either
the frenulum or prepuce in order to
allow more comfortable foreskin
retraction. Notably, experience has
taught us that to consent for either
frenuloplasty or prepuceplasty
without the other occasionally leads
to a situation where you wish you
Trends in Urology & Men’s Health ❘ July/August 2021
Figure 1. Doppler image of a left scrotal
varicocele
could do both, but are unable to as
the patient has only consented for
one procedure. The advice remains
that circumcision is rarely needed
outside of the presence of lichen
sclerosis, and that regular retraction
and steroids are often helpful but
frenuloplasty and/or prepuceplasty
may be needed in a few.
Varicocele
It is important to remember that not
all varicoceles (see Figure 1) are the
same and treatment decisions can be
difficult as surgery comes with a
complication rate (for example,
hydroceles) of up to 28%.4
Adolescent men who notice
and present with a varicocele are
an unselected group who have
noticed a new ‘lump’ in their scrotum.
Varicoceles have an incidence of
15–20% in adolescent men. These
men have an 80% chance of normal
fertility and there is no demonstrable
difference in outcome whether they
have a varicocele fixed as a teenager
or later in life.4
Other surrogate parameters,
such as differential testicular growth,5
have been used as a predictor of late
function – but none have translated
❙ 16
● Urology
into an improvement in paternity
rate.6 There are data to support the
view that testicular asymmetry in
adolescent men needs to be
regarded with caution and is not
an indication to treat on a single
measurement alone.7 However,
in their meta-analysis Silay et al.
suggest that improvement in pain
attributed to varicocele following
repair may be seen in up to 100% of
patients, although data are limited.8
It does seem to be the case that
correction of a varicocele where the
left testis is ≥20% (or ≥2ml) smaller
than the right side will lead to an
improvement in semen parameters
and a catch-up testicular growth,
but no data reliably support a
functional benefit.8
It is the view of the author that
adolescents who present with a
varicocele need to be assessed,
testicular volume measured, with
follow-up monitoring for 12–18
months. If the patient is over 16
years of age, they should be
offered a semen analysis to assess
fertility potential – although it is
important to remember that semen
analysis has considerable variability
at this age and may improve with
time.9,10 Varicoceles may be found in
30–40% of adult men who present
with fertility problems; although,
these appear to be selected
patients, data do support improved
semen parameters and paternity
following varicocele repair within
this group.11,12
a b
Figure 2. a. A testis in the inguinal canal; b. An undescended testis sitting in the
left side of the pelvis
17 ❙ Trends in Urology & Men’s Health ❘ July/August 2021
Testes not found in the scrotum
Cases of testes not found in the
scrotum (see Figure 2) are challenging.
The data in infants (incidence 5%)
and the recommendation for surgery
(ideally) before 12 months, are well
documented.13
In adolescents there are little in
the way of data or guidelines. If the
testes are palpable in the groin then
the patient needs to be told about
their increased risk of testicular
cancer, which is approximately 1.7%.14
There is a 74% increased risk of
cancer in the contralateral testes, with
approximately a six times increased
risk in the ipsilateral testis. If the
undescended testis is unilateral this
will have almost no effect on fertility,
but bilateral cryptorchidism may lead
to a marked change in characteristics
seen on testicular biopsy and semen
paramenters. Apart from in very
specific (and rare) circumstances the
testis should not be left in the groin.
It should be mobilised and, if possible,
relocated in the scrotum. It is essential
that patients are warned that if the
testis cannot be safely mobilised on its
blood supply then it will be removed.14
If a testis is impalpable in
an adolescent/adult then it is
important to gain as much history
and documentation as possible. It is
not uncommon to find (but not safe
to assume) that a testis has been
removed, but it is important not
to ignore an unrecognised intra-
abdominal testis. Imaging prior to
seeing a specialist is rarely helpful.
However, once a patient is in the clinic
there is more discretion related to the
need for imaging in an adolescent
than in a younger child (where it is
wholly unnecessary). Many young
adults in this situation have had
complex surgery in the past, which
increases the risk of laparoscopy.
Therefore, it would be prudent to get
an MRI to try to visualise the testis
and its location, and a decision can
then be made about intervention.
This decision may well involve an
MDT discussion and putting options
to a patient, and these can be difficult
decisions for both clinician and patient.
Epididymal cysts and
hydroceles
Adolescent men commonly present
to doctors with a scrotal lump or
swelling: this is important, and all
need to be seen and examined.
The appropriate medical response is
an important part of encouraging
young men to engage with testicular
self-examination as a means of
ensuring early diagnosis of testicular
cancer.15,16 In a primary care setting,
it is entirely appropriate to refer
patients to see a urologist if there is
any doubt about the diagnosis. If
there is any thought that a lump may
be testicular cancer then the effort
involved in either diagnosis, treatment
or reassurance is well spent. This
may depend on the availability and
quality of community ultrasound.
Epididymal cysts are common
(see Figure 3) and they can be single,
multiple, unilateral or bilateral. Apart
from the appearance of a lump they
usually do not cause other symptoms
and, if so, they should be left alone.
Hydroceles can be regarded in the
same way; their presence does
not make surgery necessary. A
small hydrocele that is not causing
pain, affecting activity or impacting
cosmesis does not need intervention.
The difference between an
epididymal cyst and a hydrocele
(from an examination point of view)
is that with a cyst the body of the
wchh.onlinelibrary.wiley.com

Figure 3. An epididymal cyst in relation
to the epididymal head and testis
testis can usually be distinguished as
separate from the cyst and testicular
pathology examined for. A hydrocele
will usually surround the body of a
testis and it may be difficult to ensure
that the testis feels normal. In either
case an ultrasound is reasonable and
reassuring. In adolescent men, a de
novo hydrocele is most commonly
similar to an adult hydrocele (ie there
is not usually a patent processus
vaginalis). With this in mind, it is
important to take a careful history of
when symptoms began and whether
the hydrocele varies in size. Neither
condition (in its own right) has any
impact on fertility.
Surgery is only indicated if a cyst
or hydrocele is causing significant
pain, the size is limiting activity or
there is a suspicion of other pathology
(ie malignancy). A discussion of
surgical technique is beyond the scope
of this paper. The reason for reticence
around surgery is the fact that both of
these conditions are benign, and
complications can occur in up to 30%
of patients undergoing surgery that,
although often relatively minor, would
not occur at all without surgery.17 The
particular concern relating to operating
on an epididymal cyst is causing
damage to the epididymis, resultant
obstruction and an effect on fertility –
which can occur in 1 in 50–250
cases.18 All these risks can be avoided
with conservative treatment and,
while this may not be appropriate for
all, it does mean careful consideration
wchh.onlinelibrary.wiley.com
and patient counselling is needed
before undertaking surgery.
Penile anomalies
It is common for young men to think
about whether their penis is normal
and whether it will impact their ability
to undertake sexual relationships. The
vast majority of these concerns will
settle with self-enquiry or discussions
within a family as a young man
becomes an adult.
The majority of adolescent men
referred into an adolescent clinic
with penile concerns need to be
seen, examined and reassured that
they are normal. There are important
points to consider, and erroneous
information is readily available to our
patients who need reassurance with
facts. The source of information is
important: the media and mediums
such as pornography are commonly
viewed and believed by many men
(not just adolescents), and there is
emerging evidence that watching
pornography may have a detrimental
effect on erectile function.20
It is, therefore, important that we
use peer reviewed data to provide
reassurance or appropriate treatment.
Micropenis is defined in adult men
by a stretched penile length of 7.5cm
or less.21 However, there are good
data that 60% of men with defined
micropenis can still engage in healthy
sexual relationships, although it is
acknowledged that 38% may have
psychological issues, hence, the need
for careful support and counselling
is important – but operations purely
to improve penile size have a poor
track record of efficacy and patient
satisfaction.22
For those patients with defined
anatomical anomalies such as
hypospadias (see Figure 4) many
will have had surgery in childhood.
They may have concerns about both
urinary and/or sexual function.
There are data to show that, for
many, urinary and/or sexual function
can be good, but there may be
dissatisfaction with penile appearance
Trends in Urology & Men’s Health ❘ July/August 2021
Urology ●
Figure 4. Example of a midshaft hypospadias
in up to 30%, urinary symptoms
(for example, urinary spraying) in
40–50%, erectile dysfunction in up
to 24%, and ejaculatory dysfunction
in up to 37%.23
Many patients who have had
hypospadias surgery do not need
follow-up, therefore, we do not know
the precise complication rate, but
there are now data to suggest that
with prolonged follow-up, beyond
puberty, complication rates such as
fistulae and strictures may be up to
25%.24,25 For those patients who
are found to have an unoperated
hypospadias in adolescence or
adulthood, these need careful
examination and counselling about
the value (or not) of surgery, and
those with a distal (mild) hypospadias
may not need surgery at all. Patients
who have had prior surgery that
develop problems later in life need
referral to a specialist centre for
evaluation and treatment.
Summary
Adolescent men can be a difficult
group to engage in health care, and
they can have defined urogenital
problems. It is important that when
they present with these problems
they are seen, examined and
appropriately advised. For some,
reassurance will be the correct
course, while others will need
specialist evaluation and treatment.
Care focused on adolescent
urology is a relatively new specialty,
but there are now emerging data
and expertise in this area available
❙ 18
● Urology
to support both patients and other
health care providers when necessary.
Acknowledgements
Thanks to Dr Doug Pendse,
consultant uro-radiologist at
UCLH for his help in sourcing the
radiological images in this paper.
Declaration of interests: none
declared.
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