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Pediatric Varicoceles

By Philip E. Gleason, MD

Varicoceles are varicose veins of the scrotum. The exact cause of varicoceles is unknown. They typically begin to develop and appear during puberty and the early teen-age years. They occur in approximately 15% of all men. For unknown reasons, they occur almost exclusively on the left side of the scrotum and not the right. Typically the scrotum is normal when sitting or lying down. However, with standing up or exertion or physical activity, the scrotum will become swollen with pooling of blood in the veins of the left testicle producing varicose veins and the varicocele. While most varicoceles are completely asymptomatic and are discovered only unexpectedly on routine physical exam, they can potentially cause pain or potential damage to the testicles with impairment of future fertility.

Approximately 15% of men ultimately do have symptoms with their varicoceles. Management is therefore dependent upon attempts to identify the 85% of patients who will have no future difficulties with the varicocele from the 15% at risk for future problems. Again, a few men or boys will have symptoms of pain. This is often described as a dull or aching pain in the left side of the scrotum. It oftentimes occurs through the latter part of the afternoon or into the evening after being physically active throughout the day. Oftentimes, the varicocele itself and the pain resolve upon resting or going to bed in the evening. In the morning, the patients are typically again asymptomatic only to develop recurrent pain throughout the day as mentioned.

Another potential serous complication of varicoceles is impairment of fertility. In fact, varicoceles are the number one cause of infertility in 20-30 year old men. Approximately 40% of infertile men will be found to have a varicocele. The exact cause of fertility is unknown. It is felt that with pooling of blood in the dilated veins along the left side of the scrotum, surrounding the left testicle, that the temperature inside the scrotum may, in fact, be elevated. Typically the scrotal body temperature is approximately 2 degrees cooler than the general body temperature. It appears that the increase in scrotal temperature can impair testicular growth and development including sperm production. Signs of testicular injury include slight decreased size of the testicle, known as atrophy. Correction of a varicocele will often result in recovery of the testicular injury, although unfortunately, not always guaranteed.

The management of varicoceles therefore attempts to separate those that will have no future problems with the varicocele from those at risk of future difficulties. Certainly an absolute indication for correction of a varicocele would be symptoms of pain with the hope of correcting the varicocele and resolving the ongoing pain. In addition, if there is any evidence of testicular injury or atrophy, this is also felt to be an absolute indication for correction of the varicocele to try to recover testicular function and ensure normal fertility in the future. A relative indication for correction of the varicocele is a very large varicocele. They are often times graded on a scale from being small or grade 1 to being very large or grade 3. If the varicocele is large or grade 3, it is felt to have a very high chance of causing future testicular damage. There is a growing consensus therefore, to avoid future injury by correcting the varicocele before the injury can occur rather than waiting for the injury to occur then trying to recover the testicular damage again, as mentioned above, is not always guaranteed. While the testicle will usually recover, in a significant number of men, the testicular injury is permanent with impaired fertility. If the varicocele is small and doesn't cause any pain or injury to the testicle, they can be followed conservatively with annual physical exam. They should follow a future benign natural course. If, however, fertility becomes a problem in the future, it would be prudent to re-evaluate the varicocele and consider correction.

I hope this will provide some background information regarding varicoceles and their diagnosis, management, and therapy.