VARICOCELE

VARICOCELE
• Definition: an abnormal dilatation of testicular veins in the pampiniformis plexus
caused by venous reflux
• It is unusual in boys under ten years of age and becomes more frequent at the
beginning of puberty. It is found in 14-20% of adolescents, with a similar incidence
during adulthood. It appears mostly on the left side (78-93% of cases).
• Right-sided varicoceles are less common; they are usually noted only when
bilateral varicoceles are present and seldom occur as an isolated finding
• Varicocele develops during accelerated body growth and increased blood flow to
the testes, by a mechanism that is not clearly understood.
• Severe damage is found in 20% of adolescents affected, with abnormal findings in
46% of affected adolescents. Histological findings are similar in children or
adolescents and in infertile men. In 70% of patients with grade II and III
varicocele, left testicular volume loss was found.
• In about 20% of adolescents with varicocele, fertility problems will arise [288]. The
adverse influence of varicocele increases with time. Improvement in sperm
parameters has been demonstrated after adolescent varicocelectomy.
CLASSIFICATION
Varicocele is classified into 3 grades [293]:
• Grade I - Valsalva positive (palpable at Valsalva manoeuvre
only);
• Grade II - palpable (palpable without the Valsalva manoeuvre);
• Grade III - visible (visible at distance).
DIAGNOSIS
• Mostly asymptomatic, rarely causing pain
• The diagnosis depends upon the clinical finding of a collection of
dilated and tortuous veins in the upright posture; the veins are
more pronounced when the patient performs the Valsalva
manoeuvre. The size of both testicles should be evaluated during
palpation to detect a smaller testis.
• Venous reflux into the plexus pampiniformis is diagnosed using
Doppler US colour flow mapping in the supine and upright position
• Venous reflux detected on US only is classified as subclinical
varicocele. To discriminate testicular hypoplasia, the testicular
volume is measured by US examination or by orchidometer. In
adolescents, a testis that is smaller by > 2 mL or 20% compared
to the other testis is considered to be hypoplastic.
MANAGEMENT
• There is no evidence that treatment of varicocele at paediatric age will offer a better
andrological outcome than an operation performed later. Beneficial effect of pubertal
screening and treatment for varicocele regarding chance of paternity has been
questioned according to a corresponding questionnaire in adult patients
• The recommended indication criteria for varicocelectomy in children and adolescents
are:
• varicocele associated with a small testis;
• additional testicular condition affecting fertility;
• bilateral palpable varicocele;
• pathological sperm quality (in older adolescents);
• symptomatic varicocele.
• Testicular (left + right) volume loss in comparison with normal testes is a promising
indication criterion, once the normal values are available. Repair of a large varicocele,
causing physical or psychological discomfort, may also be considered. Other
varicoceles should be followed-up until a reliable sperm analysis can be performed.
MANAGEMENT
• Surgical Repair of Varicocele: Several approaches exist to correct the adolescent varicocele: inguinal
or subinguinal, laparoscopic or retroperitoneal, or venographic. The surgical decision revolves around (1)
whether to spare the testicular artery and/or lymphatics using the available approaches, and (2) the
effect on the rate of recurrence and hydrocele formation
• Subinguinal or Inguinal Microsurgical Varicocelectomy: The subinguinal microscopic approach
provides the advantages of facilitated artery and lymphatic sparing, high rate of success, and low risk of
hydrocele but may be time-consuming and requires microscopic surgical skills.
• Retroperitoneal and Laparoscopic Varicocelectomy: The ligation of the internal spermatic vessels
above the level of the internal inguinal ring is a simple procedure performed by open or laparoscopic
approaches with high success rates but higher rates of hydrocele formation
• Sclerotherapy or Embolotherapy: The benefit of this approach is to identify and classify the venous
collateralization as possible routes of outflow and reflux. The benefits of the procedure lie in its minimally
invasive approach through a transfemoral venous puncture done under local anesthesia (with or without
sedation). However, the procedure has generally inferior success rates compared with surgical (open or
laparoscopic) procedures, involves significant radiation exposure, and is unfeasible for technical reasons
in 5% to 22% of cases