A varicocele is abnormal enlargement of testicular veins. It doesn’t typically cause any symptoms. Most adolescents who have varicocele are diagnosed during a routine physical when doctors find enlarged veins in the testicle that aren’t tender to the touch. Varicoceles are classified by size. Grade I is small, Grade II is medium, and Grade III is large.
A varicocele is the most common cause of infertility in men. Doctors have begun paying more attention to adolescent boys with varicocele because:
- a varicocele typically develops in early adolescence
- the effect of a varicocele can get worse with age
- return of normal fertility after surgery to repair varicocele in adult men who are infertile is successful in less than 50% of cases
Data suggests that a varicocele can have a significant effect upon testicular growth and function in adolescent males. In these cases, doctors prefer early treatment because delaying treatment may make growth and function problems irreversible. However, not all boys with a varicocele experience significant problems. Some experience only limited effects. In these cases, doctors usually recommend careful observation and regular follow-up visits to monitor the effects.
Most varicoceles are found on the left testicle, but they can also involve the right testicle. Blood that flows from the testicle normally drains into a vein near the kidney, but when there is a varicocele, blood flows backwards from veins near the kidney into the veins of the testicle. The most common cause of a varicocele is defective valves within the testicular vein that allow the normal blood flow to be reversed.
Currently, there is significant evidence that a varicocele can produce testicular injury in teenagers. Experts do not know the exact cause of the injury; however, they believe that a varicocele that involves one testicle can cause a temperature increase in both testes. This temperature increase can cause varying effects on the testes. Some men may become infertile or have reduced fertility, while others will retain their fertility. However, the prevailing wisdom is that the number of men who will develop fertility problems due to varicocele will increase with age. Therefore, men with a varicocele should be followed by a urologist regularly since it’s not possible to predict who will develop fertility problems and who won’t. Men with a varicocele who delay starting a family until they are older are at greater risk for infertility than those who begin having children at a younger age.
Some men worry about testicular injury following varicocele surgery and whether any injury would be reversible. Evidence suggests that the odds of successful reversal or stabilization of testicular injury are better with early treatment and that there may be a point after which treatment won’t be successful. Currently, we cannot predict whether a male with a varicocele will have normal fertility even if he is treated early. However, there are studies that show when individuals with a varicocele and smaller left testicle are treated early, they have significantly improved chances of achieving normal fertility over untreated patients.
Doctors usually decide whether adult men with a varicocele should have surgery based upon documented evidence of infertility and an abnormal semen sample. When it comes to adolescents, these criteria aren’t used because infertility hasn’t been documented and it’s difficult to obtain a semen sample. However, it is not reasonable to postpone treatment of all adolescents who have a varicocele because some of them may become infertile if they aren’t treated as adolescents. On the other hand, there is no data to support performing corrective surgery on every person with a varicocele because not all of them will become infertile.
Because of the uncertainty of the effects of a varicocele, there aren’t any solid guidelines for recommending surgery in adolescents. However, most experts agree that surgery should be considered if at least one of the following abnormalities is present:
- abnormal semen analysis
- the testicle on the side of the varicocele is smaller
- the varicocele involves both the right and left sides
When surgery is not recommended, all people who have a varicocele should have annual testicular exams to ensure the testicles are growing normally. Also, after boys turn 17, they should have an annual semen analysis to check fertility. As long as the testicular exam and semen analysis remain normal, surgery won’t be necessary. That said, a single normal semen analysis does not guarantee normal fertility since new abnormalities can develop over time. Therefore, it is important for men with a varicocele to have annual exams to check fertility until he no longer wishes to have children.
Surgery to repair a varicocele involves relatively few risks. The risks include increased fluid around the testicles (hydrocele) and recurrence of varicoceles, which affects approximately 2 to 3% of the males who undergo repair.
Varicocele repair methods include:
Open (traditional) surgery is typically done on an outpatient basis. The surgeon usually uses general anesthesia to put patients to sleep during the procedure. We make an incision on the abdomen (retroperitoneal incision) to reach the affected vein. Then we identify the affected, dilated veins and tie them off from the blood supply.
Recovery after surgical repair is usually relatively quick. Most doctors advise their patients to return to normal, non-strenuous activities after two days. As long as your child is comfortable and not having pain, he may return to more strenuous, normal activity, like exercising, after about four weeks. He shouldn’t experience any severe pain. Most people experience only mild pain. Your child’s doctor may write a prescription for pain reliever for the first two days after your procedure, but after that, your child will likely only need to take over-the-counter pain medication, such as acetaminophen (Tylenol) to relieve any discomfort.
During laparoscopic surgery, your child’s surgeon will make three small incisions in the abdomen. Then he or she will pass tiny instruments through those incisions to help see and repair the varicocele. The success rates for laparoscopic surgery are about the same as open surgery success rates.