Varicocele is the enlargement of the veins of the testicle, that is, varicose veins. At older ages, after marriage, these patients usually apply to Urology outpatient clinics due to infertility. Sometimes there is swelling or pain in the scrotum. Childhood varicocele is a disease seen in adolescence. This disease is an important disease as it will cause testicular damage and problems such as infertility and impotence (erectile dysfunction, erectile dysfunction) in the future.

In this article, I will give general and up-to-date information about varicocele disease, symptoms and treatment seen in childhood, in the light of the literature, taking into account our own experiences.

What is childhood varicocele?

Varicocele is varicose dilation of the veins of the testicle (pampiniform plexus). In other words, it is the varicose vein of the testicles. Varicocele cases seen in childhood are called “childhood, adolescence, pubertal varicocele, adolescence varicocele”. It is often seen in boys after puberty. Puberty is defined by the World Health Organization (WHO) as the period between the ages of 10 and 19. Varicocele is seen in approximately 15% of all men, 19-41% of primary infertile men, and 80% of secondary infertile men. It is a cause of infertility that can be treated surgically. It is seen in less than 1% in the period before puberty and in 5-30% of boys between the ages of 12-18.

Evaluation of patients with childhood varicocele

Children with adolescent varicocele are evaluated in detail urologically. Steps to consider in the evaluation of these patients are as follows:

• Medical history: Information about testicular swelling, pain, whether there is varicocele in siblings, and the onset of the disease are investigated.
• Examination: Varicocele patients are examined while standing. The volume and consistency of both testicles, the degree of varicocele, penis and other scrotal contents are evaluated.
• Testicular volume: Testicular volumes are determined by Prader orchidometry or scrotal ultrasonography (USG).
• Doppler USG: With scrotal Doppler USG, the width of the testicular veins and the presence of varicocele are evaluated.
• Spermiogram: Spermiogram is controversial in childhood varicocele patients. We generally do not request a spermiogram test.
• Endocrine evaluation: In varicocele, the hypothalamo-pituitary-gonadaal axis may be affected and testosterone production may be impaired. This condition is related to the duration and degree of varicose veins.

Can varicocele be familial?

Studies on varicocele have shown that this disease is familial, that is, hereditary. In this regard, the chance of this disease is higher in those whose siblings or first-degree relatives have varicocele.

How is childhood varicocele detected?

Since varicocele usually does not cause serious pain, patients do not notice it and do not consult a physician. In adulthood, a doctor is consulted for testicular shrinkage, swelling in the scrotum, or often infertility. In order to detect varicocele in children, screening should be done, or patients admitted to the hospital should be examined for varicocele by scrotal examination. It is important to raise awareness of families on this issue. It is important for those whose siblings have varicocele to be checked by a urologist.

On which side is varicocele most common?

Varicocele disease is mostly seen on the left side. It is less on the right. It is rarely seen on both sides. In the studies conducted, % …. on the left by %, …. It has been reported that it is seen on both sides. In varicoceles occurring on the right, conditions such as a mass that prevents the rotation of the right testicular vein (Wilm’s tumor, retroperitoneal mass) or situs inversus totalis (organs congenitally develop on the opposite side) should be considered.

What are the causes of varicocele formation?

The exact cause of varicocele is not known. It is thought that it may be due to the insufficiency of the valves in the veins. The reason why it is more common on the left is due to the fact that the left testicular veins travel a longer distance and open at a right angle to the vein. On the left, the testicular veins open at a long right angle to the left renal vein and the path is longer than the right. On the right, it opens into the vena cava (main vein in the abdomen). The angle is narrower and the distance is shorter than to the left.

How is varicocele examined in children?

In general, varicocele examination is performed while the patient is standing. Because during inpatient examination, the veins are emptied and therefore varicocele cannot be detected. We perform childhood varicocele examination in an outpatient position, just like in adults. The examination is performed while the patient is standing, breathing deeply and in a normal state. During the examination, the consistency, size and other scrotal contents of both testicles are evaluated. In addition, secondary sexual characteristics such as penis development and pubic hair development are also evaluated.

Childhood varicocele classification (grade)

Varicocele grade refers to the width of the testicular veins (veins) on the side with varicocele. In other words, it shows the size of the varicocele. We classify childhood varicocele into 3 groups (grades), just like in adults:

• Grade 1: If there is a varicocele during an outpatient examination when the patient closes his mouth and nose and inflates his abdomen (Valsalva maneuver), this is called grade 1 varicocele.
• Grade 2: If the varicocele is palpable without straining when the patient is examined standing, it means that there is a grade 2 varicocele.
• Grade 3: If a varicocele is visible when the patient is standing, this means that there is a grade 3 varicocele.

Is a spermiogram necessary for those with childhood varicocele?

There is no need for a spermiogram test in children with varicocele. Because sperm production is not fully mature at this age. At this age, spermiogram is both misleading and traumatic for the child. For these reasons, we do not require a spermiogram test in varicocele patients in childhood.

How is childhood varicocele diagnosed?

Diagnosing varicocele in children, as in adults, is possible with physical examination. An outpatient examination is sufficient to make a diagnosis. USG may be performed to better evaluate the internal structure and size of the testicles. There is no need for a spermiogram test.

If there is a childhood varicocele, in what cases is surgery absolutely necessary?

People with childhood varicocele usually do not have any complaints. Very rarely, pain and swelling occur. At these ages, follow-up with spermiogram values ​​is not accurate. If there is a varicocele in childhood, surgery must be performed in the following cases.

• If there is grade 2 and grade 3 varicocele
• If there is a volume difference (reduction) of 2 cc or more between two testicular volumes
• If there is a significant varicocele on both sides
• If there is pain and swelling

What happens if varicocele in children is not operated on/treated?

Childhood varicoceles must be operated on. If left untreated, serious problems will arise in the future. These:

• Testicular atrophy
• Infertility (sterility)
• Erectile dysfunction
• Hypogonadism

How to prepare before surgery?

Varicocele surgery is performed under general anesthesia, rarely it can be performed with spinal anesthesia. Preoperative preparation of patients is as follows:

• Routine blood tests are taken
• Patients are evaluated by an anesthesiologist and, if necessary, a pediatrician.
• Patients stop eating and drinking by mouth 4-5 hours before the surgery.
• Preventive antibiotics are started before surgery
• On the day of surgery, the patient is taken into surgery after being admitted to the hospital and signing the necessary consent forms.

How many hours does the surgery take, what kind of anesthesia is given, how many days of hospitalization?

We perform varicocele surgery under general anesthesia. It takes approximately 30-45 minutes. We usually discharge our patients 5-6 hours after surgery or keep them in the hospital overnight.

How is adolescent varicocele treated/surgery performed?

Treatment of varicocele is possible with surgery. It is not possible to treat varicocele with medication or herbal methods. The only treatment option is surgery. The most effective method preferred today for varicocele surgery is “microsurgery” surgery. Laparoscopic surgery is not recommended in the treatment of varicocele. It is an abandoned form of treatment because the recurrence rate in surgeries performed with laparoscopic technique is very high. Radiologically, embolization of varicose veins is not a preferred method.

With microsurgery, the spermatic cord is located through a 2-3 centimeter incision in the groin. Enlarged veins are found, cut and tied. Since we do it under a microscope, the arteries, lymph vessels and seminal ducts of the testicle are protected. Since the surgical incision is closed aesthetically, there is no scar left afterwards.

What are the complications of surgery?

If varicocele surgery is performed with microsurgery, complications are very low in experienced hands and the success rate is high. Although rare, complications that may occur due to surgery include:

• Testicular atrophy as a result of damage to the testicular artery
• Development of hydrocele (fluid accumulation around the testicle) as a result of ligation of lymphatics
• Damage to the ductus deferens (semen duct)
• Wound infection
• Scar development at the incision site

Can testicular atrophy in children be corrected by surgery?

One of the most important complications of varicocele is testicular atrophy, that is, shrinkage of the testicle. As a result, infertility and impotence may develop in these people at later ages. If testicular atrophy develops in childhood varicocele patients, it is corrected with surgery and the testicle returns to normal size. However, atrophy due to varicocele in adult testicles cannot be corrected by surgery. For this reason, we always perform surgery on childhood varicoceles.

What is the best method for treating adolescent varicocele?

The best method for treating adolescent (childhood) varicocele is microsurgery. The success rate is high and complications are almost non-existent. Microsurgery method is the gold standard treatment

Which doctor should perform surgery on pediatric varicocele?

Both urologists and pediatric surgeons can perform childhood varicocele surgery. Urology specialists are much more experienced in this regard. Varicocele patients generally consult a Urologist due to infertility after marriage. Urology specialists are more experienced and knowledgeable in this regard. Varicocele causes damage to the testicles, leading to serious problems such as infertility and impotence in adulthood. Since varicocele-related problems will be seen in later ages and urologists deal with these issues, it is more correct for this surgery to be performed by a urologist.

Follow-up after childhood varicocele surgery

Patients are discharged 5-6 hours after the surgery, sometimes we keep them in the hospital for a day. Postoperative follow-up:

• Painkillers are given for pain.
• Protective antibiotics against infection are started
• Rest is required for about 1 week
• The wound area should be kept dry for about 1 week.
• Heavy sports should not be done or weight lifting should be avoided for 3-4 weeks.
• Testicular volumes are evaluated during controls.
• Hormonal tests are requested if necessary.
• A spermiogram is requested for control purposes in the adult period.

In summary: Varicocele in children is a silent disease. Since it does not cause serious pain, patients rarely complain about pain and sometimes swelling. Screening for the diagnosis of childhood varicocele and raising awareness among families are important. The most effective and gold standard treatment is “microsurgery”. There is no need to request a spermiogram test in children since sperm production is not fully mature. If atrophy has developed due to varicocele at this age, the testicle completes its normal growth after surgery. Surgery should be performed in adolescent varicoceles as it will cause problems such as infertility and erectile dysfunction in the future.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY