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Pediatric varicoceles.

A common cause of painless swelling of the scrotum in boys is a varicocele. About 10-15% of males have a varicocele--an abnormal enlargement of the veins surrounding the testis and spermatic cord. While varicoceles occasionally cause discomfort, most are painless. What makes varicoceles medically important is that they can cause atrophy, or shrinking, of the testis during adolescence. Varicoceles can furthermore cause infertility in adulthood.

Varicoceles of the spermatic cord, like varicose veins in the legs of adults, occur when the one-way valves found in those veins do not work properly, allowing blood to flow backward through the veins. When valves in veins do not work, blood pools in lower parts of the body such as the legs and the scrotum.

In the case of scrotal varicoceles, this defect is an inborn one, but it tends not to become visible until after the age of 10. The testes function best at a slightly cooler temperature than the rest of the body. When there is a varicocele, warm blood from the abdomen flows "backward" around the testis and the testes as a result become abnormally warm, and this can cause atrophy of the testis and low sperm counts.

Because pre-adolescents tend to be very private about abnormalities in their genitals, especially when they are not painful, most varicoceles are detected by a routine physician examination, such as a sports physical. Varicoceles are assessed as being subclinical, Grade I, Grade II, or Grade III.

Subclinical and Grade I varicoceles will only be detected in adults who are being evaluated for infertility, since they require special examinations to detect. A Grade II varicocele is an enlargement and dilation of the veins that can be felt by an examiner's hand, while a Grade III varicocele is so extremely dilated that it can be seen with the naked eye. The classic description of a large Grade III varicocele is that it looks and feels like a "bag of worms."

The other important part of an exam is to determine if there is atrophy of the testis. Ways of measuring testis size can be as simple as examination by an experienced urologist, comparing the affected side to the presumably normal side, or they can be as complex as the formal measurement of testis volume using ultrasound, comparing these volumes to published normal ranges for a child's age. In most cases, testicular atrophy is quite obvious and can readily be noted on simple examination.

In childhood, the two primary reasons to treat a varicocele are pain and testicular atrophy. Since a large majority of children with varicoceles will not have infertility problems as adults, routine treatment of varicoceles in an attempt to prevent later infertility problems is not warranted, as long as there is no testicular atrophy.

Painless varicoceles in adolescents should simply be observed for the development of testis atrophy, and the adolescent and his parents should be counseled about the possibility of future infertility problems as an adult, whether or not atrophy occurs.

An area of controversy involves large (Grade III) varicoceles found prior to puberty. Because a majority of boys with large varicoceles found prior to puberty will experience significant atrophy, some urologists recommend routinely treating Grade III varicocele found under these circumstances.

In any event, parents and child should be reassured that an atrophic testis almost always quickly catches up with the growth of the unaffected side--often seeing noticeable improvement within weeks of treating the varicocele. Likewise, if there is infertility from a varicocele later in life, the rates of improvement of sperm counts after repair are very high, regardless of the age at which treatment occurs.

If treatment of a childhood varicocele is necessary, there are a number of techniques available. First, there is a "venography" technique that can be done by an interventional radiologist. A catheter is used through a large vein in the groin, similar to the kind of catheter used in a cardiac catheterization. Under X-ray guidance, the affected vein is located at the point where it empties into the left renal vein, and it is embolized by injecting substances into the spermatic vein in order to occlude it, thus preventing any back-flow of blood. When successful, this is perhaps the least invasive technique, but failure rates are high.

A second technique is a "subinguinal" microscopic technique. By working under a microscope, the surgeon is able to operate in the area just above the scrotum, meticulously dissecting out all veins and tying them off with suture. The primary risk to this technique is that the very small arteries going to the scrotum can be injured at this point, causing testicular atrophy or even loss.

A third common technique is a laparoscopic approach. Using tiny incisions in the abdominal wall, the abdominal cavity is inflated with carbon dioxide, the affected spermatic cord is located internally with a laparoscopic lens and camera, and it is dissected free from the surrounding tissues and divided.

Some urologists use Doppler ultrasound to help them find the tiny testicular artery found in the cord in order to spare it, although there is no evidence that sparing the testicular artery improves outcomes. Testicular injury almost never occurs with a laparoscopic technique, since other blood supplies to the testis aren't disturbed. On the other hand, there are some additional slight risks to internal abdominal structures such as bowel.

In summary, pediatric varicoceles are a relatively common finding in childhood, but rarely require intervention. If intervention is necessary, there are numerous good surgical options available to the treating urologist, and overall success rates are very high.

By Bradley Anderson, MD

Bradley W. Anderson was trained at the University of Oklahoma, and is board certified in adult and pediatric urology. He practices urology at St. Vincent Healthcare, a regional medical center in Billings, MT.
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Title Annotation:Urologist's Notebook
Author:Anderson, Bradley
Publication:Pediatrics for Parents
Geographic Code:1USA
Date:Mar 1, 2012
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