A guide for parents of adolescent with varicocele
What is varicocele?
Varicocele can be defined as the excessive dilation of the veins carrying the dirty blood coming from the testicles and the accumulation of the blood inside. In this case, the dirty blood carrying waste materials cannot be removed, and at the same time, the temperature increase caused by the accumulated blood begins to disrupt the work of the testicles. In addition to symptoms such as pain where the testicles are located, it can cause infertility as a result of regression in testicular development, atrophy (shrinkage) and deterioration of sperm values in adulthood. Varicocele is a common disease in the adolescent age group. Although the incidence of adolescent varicocele is 15%, it increases with age after 13 years of age, when growth accelerates. Left varicocele is seen in 90% of cases, while bilateral varicocele is seen in approximately 10% of cases.
How is it diagnosed?
Most of the varicocele cases in childhood and adolescent age group do not give any symptoms. They are usually detected incidentally by physical examination or noticed by families.
When a careful physical examination is performed in cases with varicocele, volume loss is detected in the testis on the affected side in approximately 10% of the cases. Physical examination is the gold standard for the diagnosis of adolescent varicocele. The physical examination should be performed in a warm environment with the patient standing and lying down.
Diagnostic color Doppler ultrasonography does not have a place in every case. However, in cases with severe left varicocele and in adolescents with abnormal sperm parameters, color Doppler ultrasonography may be necessary in terms of the necessity of bilateral varicocele treatment.
Measuring testicular volumes is necessary in terms of the necessity of varicocele treatment and monitoring of testicular volumes after varicocelectomy. Testicular volumes can be measured by ultrasonography as well as by various volume meters (orchidometer).
What are the treatment indications?
Treatment indications in adolescent cases with varicocele have not been fully clarified. Two ml in the affected testis compared to the other testis or greater than 10% volume loss are the indications of the definitive treatment. It is known that testicular pain is an uncommon cause of presentation in adolescent varicocele and its frequency is only 3-4%. Although it is known that varicocele impairs sperm parameters, spermiogram is not always possible in the adolescence age group. Therefore, it is necessary to wait for the appropriate age. For these reasons, we can count testicular shrinkage and pain as surgical treatment criteria.
How is the surgical procedure done?
The aim of varicocelectomy is to ligate all problematic veins. During this procedure, the vas deferens (semen duct), lymphatic vessels of the spermatic cord and testicular arteries should be protected.
Treatment options in adolescent varicocele cases are open surgery, laparoscopic surgery and treatment with radiological methods. However, current treatment methods are ligation of testicular veins with open inguinal (inguinal region) or subinguinal (under the inguinal region) approaches performed with microscope or magnifying loops.
How is the follow-up done in the pre- and post-operative period?
About 6 hours of fasting is sufficient before the operation. Prophylactic antibiotic treatment is given as a single dose on the day of the operation. Adequate amount of fluid is determined according to age and weight, and fluid is given intravenously throughout the operation day.
After sufficient bowel movements have started after the surgery, the patient can start to eat. In general, the patient can leave on the same day or the day after the surgery. Daily dressing of the surgical site is required. Although absorbable sutures are often used for the skin, if non-absorbable sutures are used, the sutures can be removed 1 week after the operation.
What are the complications of surgery?
Although it varies according to the method applied and the person who applies it, the important complications of varicocele treatment are fluid collection around the testis (hydrocele), testicular shrinkage (atrophy) and recurrence. An optical magnifier should be used to reduce such complication rates. While no recurrence and hydrocele were found after microscopic varicocelectomy in a large series comparing the methods of varicocelectomy in adolescents according to the use of optical magnifying glasses, 4% recurrence and hydrocele were found with magnifying glasses, recurrence was found in 11.5% and hydrocele in 7.7% of the cases who underwent varicocelectomy with the naked eye. The use of a microscope as an optical magnifier minimizes the postoperative complication rates.
Hydrocele, which occurs secondary to the ligation of the lymphatic channels of the testis, is the most common complication of varicocelectomy and is seen at a rate of 1-30%.
Recurrence rates are 0-15% according to the applied method.
Injury or ligation of the testicular artery, which may lead to testicular atrophy and/or risk of impaired sperm production, is a rare complication of varicocelectomy.
How is the post-operative follow-up done?
After varicocele treatment, the cases should be followed up regularly at regular intervals. Recommended annual evaluation with scrotal ultrasonography, semen analysis, and physical examination. In controls, testicular volume, consistency, and shrunken testicles should be examined after the operation. Historically, most of the studies focused on the reactive growth of the affected testis, which is observed in 50-90% of the cases. Similarly, varicocelectomy leads to improvement in semen parameters in 50-80% of patients. Testicular consistency returns to normal after varicocelectomy in all cases in which softening of the testicular consistency is detected before the operation.