Adolescent varicocele, a Gordian knot: A comprehensive review of clinical perspectives and future directions

Abstract

The abnormal dilatation of the spermatic veins, or varicocele, affects 14%-20% of teenagers, a proportion similar to that of adults, which peaks in late adolescence (15-19 years old). It is more common in metropolitan and developed areas, possibly due to increased access to medical attention and diagnostic resources. Treatment myths and beliefs about adolescent varicocele (AV) persist, making it a highly disputable condition to address. Concerns include whether surgical intervention is necessary for teenage varicocele and whether it enhances seminal parameters after varicocelectomy. Inadequate or delayed management may contribute to future infertility, imposing a significant public health and economic burden due to the costs associated with assisted reproductive technologies and psychosocial impacts. This minireview addresses common misconceptions about teenage varicocele and clarifies the clinical assessment, treatment, and long-term effects of varicocele in adolescents. This minireview examines and provides information on essential topics, including etiopathogenesis, evaluation, and groups of patients at risk of infertility, emphasizing the importance of testicular volume asymmetry (greater than 20%) and semen parameters in predicting future subfertility. Principles of management, indications, and choice of intervention (follow-up, surgical, and adjunctive treatment) are explored, along with treatment outcomes, to address this challenging situation. A balance between intervention and cautious follow-up is emphasized in the evidence-based suggestions for treatment strategies, which depend on the clinical examination, scrotal Doppler, and semen parameter findings. Based on testicular asymmetry, semen parameters, and symptomatology, management strategies range from conservative surveillance to surgical varicocelectomy and minimally invasive procedures like embolization. AV is a complex condition. If untreated, it can cause oligospermia, infertility, and irreparable testicular damage. Timely intervention, such as subinguinal microsurgical varicocelectomy, is essential after an early diagnosis is made by clinical examination supported by Doppler ultrasound and semen analysis for symptomatic, bilateral palpable, or asymptomatic unilateral varicoceles with testicular asymmetry greater than 20% and abnormal semen parameters in Tanner V boys. Long-term data indicate that patients who have had surgery have better testicular growth and semen characteristics; nevertheless, the effect on future fertility is still being studied, indicating the need for individualized treatment plans. Testicular health, with preserved reproductive potential, is maintained through proactive evaluation and care. AV can affect quality of life in addition to causing physical discomfort; worries about fertility, body image, and social stigma call for comprehensive, patient-centered care.

Key Words: Adolescents; Infertility; Microsurgery; Oligospermia; Varicocele

Core Tip: Adolescent varicocele, a complex and often controversial condition, affects up to 20% of teenage males. This minireview examines the etiopathogenesis, diagnostic challenges, and the evolving role of testicular volume asymmetry and semen analysis in informing management. By synthesizing current evidence, we provide practical, risk-stratified recommendations for observation and surgical intervention, including subinguinal microsurgical varicocelectomy. The article highlights critical gaps in adolescent-specific research and proposes future directions to safeguard long-term fertility and testicular health.

INTRODUCTION

The abnormal dilation of the spermatic veins, known as a varicocele, affects 14%–20% of teenagers, a proportion similar to that of adults[1]. While controlling varicocele in adolescent boys poses substantial complications, it may be quite simple to treat in married men with primary infertility. Testicular hypotrophy and dysfunction are known to result from varicocele, and 20% of affected boys may have infertility in the future[2,3]. Trends over time indicate rising detection rates, which may be attributed to increased awareness and improved non-invasive testing techniques. The majority of cases are diagnosed between Tanner stages II and V, and the disorder is strongly linked to pubertal progression[4]. Treatment myths and beliefs about adolescent varicocele (AV) persist, making it a highly disputable condition to address.

Whether teenage varicocele causes oligospermia and infertility, determining the subgroups at risk of subfertility, the long-term repercussions of untreated varicocele and the psychological impacts on both treated and untreated individuals are common questions that come up. Concerns include whether surgical intervention is necessary for teenage varicocele and whether it enhances seminal parameters after varicocelectomy. This minireview addresses common misconceptions about teenage varicocele and offers information on these critical topics.

WHY IS AV IMPORTANT

Epidemiology

Varicocele is less common (less than 1%) in boys who are not yet in puberty. Older boys commonly suffer from AV, which peaks in late adolescence (15–19 years old). The incidence is approximately 7.8% for those aged 11-14 years and 14% for those aged 15-19 years. It is more common in metropolitan and developed areas, possibly due to increased access to medical attention and diagnostic resources. Testicular hypotrophy is observed in 9.3% of the teenagers in this group who are older than 15[4]. As people age, varicocele becomes more common. In adult men, varicocele prevalence increases by approximately 10% with each decade of age, reaching up to 75% in the eighth decade, as reported by Levinger et al[5]. This trend is based on cross-sectional adult data and does not represent a direct progression from adolescent prevalence[5]. Most teenage varicoceles are discovered by chance by a general care physician; most are asymptomatic and commonly occur on the left side.

Etiology and pathogenesis

Various theories have been proposed for the etiology. They are (1) Lack of valves in the pampiniform plexus veins has been more prevalent in adolescent boys with varicocele, favoring congenital venous abnormalities in its formation; (2) Increased hydrostatic pressure due to an extended drainage channel; (3) The left gonadal vein drains into the left renal vein at a 90-degree angle; and (4) The "nutcracker phenomenon" is a constriction of the left renal vein due to a reduction of the angle at the origin of the superior mesenteric artery from the aorta[6].

Varicocele occurs mainly on the left side. Isolated varicoceles are uncommon on the right side. Therefore, renal ultrasound (US) should be considered in these patients to rule out a retroperitoneal mass or extension of a renal lesion into the renal vein and inferior vena cava[1,7]. The primary cause of the pathophysiology is elevated reactive oxygen species, which in turn lead to thermal stress, oxidative stress, hypoperfusion of the testicles, and stasis of toxic metabolites. Even in cases where semen analysis is normal, this results in considerable fragmentation of sperm DNA in teenagers with varicocele[8].

PEDIATRIC PERSPECTIVES

The frequency of varicocele occurrence was 0.8% in boys aged 2–6 years, 1% in boys aged 7–10 years, 7.8% in boys aged 11–14 years, and 14.1% in boys aged 15–19 years in a cohort of 4052 Turkish children and adolescents[4]. This suggests that the prevalence increases as puberty begins. As varicocele interferes with Sertoli cell development and production of hormones during the childhood period, which is crucial for testicular growth and spermatogenesis, it leads to issues related to sperm abnormality and future subfertility[9].

The clinical examination, aided by Doppler US, is considered significant during evaluation. Management strategies are guided by the presence of symptoms and sperm abnormalities, while conservative approaches may be appropriate for those without such issues. Moderate evidence is documented in the literature stating that the treatment of varicocele aids in improving testicular volume and sperm concentration. Cannarella et al[10], in their review, concluded that to maintain future fertility and testicular health, it is crucial to diagnose and treat varicocele in a subset of children and adolescents with testicular asymmetry as soon as possible.

WOULD AV RESULT IN IMPAIRED SPERMATOGENESIS AND INFERTILITY

Teenagers with oligozoospermia and varicocele had lower heat shock protein A2 (HSPA2) mRNA expression. This protein creates a protective barrier against heat-related stress. Adolescents with varicocele, which causes oligozoospermia, had lower levels of HSPA2 than boys and adolescent males with normal semen characteristics[11]. Teenage boys with varicocele who underwent immunohistochemical examination of their testicles revealed localized damage at the level of the peritubular basal laminae[12]. Depending on the degree of varicocele, AV causes a considerable drop in testicular volume and total sperm count[13].

Controversial evidence exists regarding the influence of different grades of varicocele on semen parameters[14]. Al-Ali et al[15] concluded that patients with grade III varicocele had twice as many cases of oligozoospermia as those with lower-grade varicocele (grades I or II). Additionally, they reported that sperm density dropped dramatically as the varicocele grade increased. Shiraishi et al[16], however, found no discernible link between semen quality and varicocele grade.

WHICH SUBGROUP IS AT RISK OF BECOMING SUBFERTILE IN THE FUTURE

Numerous variables, including testicular asymmetry, testicular volume, and the Doppler US measure of maximum vein diameter and peak retrograde flow (PRF), have been studied in the past and present as potential predictors of future infertility.

Sufferers with the following findings may develop future abnormal sperm parameters: (1) 20% testicular asymmetry; (2) Bilateral small testes; and (3) Boys with a PRF of 38 cm/second or more, as determined by a Doppler and 15% asymmetry or more[17].

According to recent research, in teenagers with varicocele, total testicular volume (TTV) may be a better indicator of semen quality than testicular volume discrepancy (TVD). Thus, tracking TTV can help inform prompt intervention measures and offer insightful information about the possible risk of subfertility[18]. Testicular function and spermatogenesis can be better understood by incorporating hormonal assays, such as measurements of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). In teenagers with varicocele, elevated FSH may be a sign of decreased spermatogenesis and an additional risk factor for subfertility[19]. Adolescents with varicocele often present with asymptomatic testicular asymmetry and are primarily managed to prevent future fertility issues.

In contrast, adults typically present with infertility concerns and may have established testicular damage. These differences necessitate age-specific evaluation and management strategies. Although varicocele is a significant risk factor for male infertility, other known predictors include lifestyle variables, including smoking and obesity, hormone imbalances, and genetic abnormalities like Klinefelter syndrome. Accurate diagnosis and treatment require a detailed evaluation[20].

EVALUATION OF AV-ROLE OF TESTICULAR VOLUME ASSESSMENT AND SEMEN ANALYSIS

Physical examination is a mainstay for evaluating varicocele and diagnosing this challenging condition in adolescents. Clinical grading is done in a standing posture. However, the varicocele grade itself fails to be a good predictor of testicular asymmetry in the future[17]. According to Dubin's grading, grade I is varicocele palpable only on the Valsalva maneuver, grade II is varicocele palpable without the Valsalva maneuver, and grade III varicosity is visible through the scrotal skin[21]. No differences in testicular volume or semen parameters were found between varicocele grades by Diamond et al[22]. Although physical examination remains the primary method for evaluating varicocele, its ability to predict long-term reproductive outcomes is limited. According to recent studies, the physical examination-based varicocele grade does not always correspond with semen parameters or testicular function. Hence, additional diagnostic tests are required for a thorough assessment[19].

Testicular volume assessment becomes more relevant in these boys as semen analysis cannot be performed in all of them. Clinically, it is done by Prader orchidometers. Annual clinical examinations, which include testicular volume assessment using an orchidometer, are recommended by the Children's Hospital of Philadelphia. Semen analysis, including androgen hormone level testing, is conducted once the boy reaches Tanner stage 5 maturity[23]. Table 1 shows the Tanner stages of male pubertal development described for clinical reference. Tanner staging a sexual maturity grade is a commonly used system to record and follow a child's secondary sex characteristics as they progress through puberty[24].

Table 1 Tanner stages of male pubertal development.

Stage	Pubic hair scale	Male external genitalia scale
I	No hair	Testicular volume < 4 mL or long axis < 2.5 cm
II	Downy hair	4-8 mL (or 2.5-3.3 cm long), 1st pubertal sign in males
III	Scant terminal hair	9-12 mL (or 3.4-4.0 cm long)
IV	Terminal hair that fills the entire triangle overlying the pubic region	15-20 mL (or 4.1-4.5 cm long)
V	Terminal hair that extends beyond the inguinal crease onto the thigh	> 20 mL (or > 4.5 cm long)

Some studies suggest imaging by Doppler US, if necessary, can be done in clinically equivocal cases. Still, according to guidelines from the European Association of Urology (EAU), scrotal Doppler US should be used in conjunction with clinical examination[25]. Testicular volume is calculated by the Lambert formula (volume = length × width × height × 0.71)[26]. A testis smaller by > 2 mL or 20% of the other testis is considered an indicator of testicular function decline[27]. Recent studies have shown measurements of testicular volume are now more accurate thanks to recent developments in imaging technology. US measurements of TTV are a reliable indicator of semen quality[18].

For varicocele, the Sarteschi/Liguori classification is the most prevalent and recommended ultrasonography grading method[28]. Salient features of this classification are highlighted in Table 2. If the varicocele is bilateral and severe, both testes can shrink. A "Severe" varicocele was described by the European Academy of Andrology US consortium as a venous dilatation (> 3 mm) characterized by continuous venous reflux at rest, irrespective of whether it increases or remains normal during a Valsalva maneuver[29]. It is in line with the Sarteschi/Liguori classification of grade 4 and 5 varicoceles.

Table 2 Sarteschi/Liguori ultrasonographic classifications of varicoceles.

Grades	Reflux	Engorged vessels/varicosities	Relationships of the varicosities with the testis	Reflux or varicosities in supine/standing position with/without Valsalva maneuver	Testicular size
I	Inguinal reflux present	Non-engorged vessels	-	Reflux only during Valsalva while standing	Normal
II	Reflux present	Varicosities present	Supra-testicular varicosities	Reflux only during Valsalva while standing	Normal
III	Reflux present	Varicosities present	Peri-testicular varicosities	Reflux while standing and during Valsalva	Normal
IV	Reflux present at rest	Varicosities present	-	Reflux at rest, increasing during Valsalva. Enlarged vessels in supine and standing positions increasing caliber during Valsalva	Possible testicular hypotrophy
V	Reflux present at rest	Varicosities present	Intratesticular varices may be present	Reflux at rest, not increasing during Valsalva. Enlarged vessels in supine and standing positions	Testicular hypotrophy

It is yet unknown how useful it is to get a baseline hormonal evaluation to identify teenagers who are at risk of infertility and how important it is to know how testosterone levels vary before and after an intervention. However, elevated FSH and LH levels can be observed in the presence of testicular hypoplasia with a varicocele[27].

Due to fluctuations seen in semen parameters, single semen evaluation is inadequate. In a study of 199 patients, semen analysis was reported as normal in 55% of their first sample, 67% of their second sample, and 69% of their third sample[30]. Hence, a minimum of two occasions of semen analysis is needed to evaluate the testicular function. Oligospermia and azoospermia have been correlated with higher Sarteschi/Liguori varicocele grades. Findings from Ogunjimi et al[31] indicate that abnormal semen parameters are significantly related to Sarteschi/Liguori grades, becoming apparent from grade 3 and above.

INDICATIONS FOR TREATMENT

European Society for Pediatric Urology guidelines[1] recommend intervention in the following situation: (1) Symptomatic varicocele (pain and cosmetic); (2) Small testis with varicocele; (3) Additional testicular issues affecting future fertility; (4) Palpable bilateral varicocele; and (5) Sperm abnormalities (in post-pubertal adolescents). The AUA 2024 Plenary Recap on AV and Current Clinical Management concluded that Indications for treatment in AV are still developing, and patients with abnormal total motile sperm count at Tanner stage 5 are candidates for AV correction[32].

A survey conducted among pediatric urologists to assess AV's evaluation and treatment model sheds light on lacunae in the holistic assessment and follow-up of these boys. While 14% of urologists opted to keep the patients under observation, 3% operated them at diagnosis. The remaining 83% followed indication-tailored surgery. Ipsilateral decrease in testicular size (96%) is the most typical indication, followed by testicular or scrotal pain (79%), decreased semen parameters (39%), and anticipated fertility issues (19%). A total of 89% of physicians were unaware of the fertility considerations pertinent to the follow-up care of these adolescents[33].

MANAGEMENT PRINCIPLES OF AV

Preserving fertility is the primary aim of treatment for teenage varicoceles. Subclinical varicoceles to be managed with a conservative approach[34]. The AVs with normal testicular size on the same side should be given an option of follow-up monitoring with objective measurement of testicular size and/or semen analysis every year, according to the AUA Best Practice Guidelines for Varicocele[30,35].

Even if testicular volume asymmetry of 20% or more could indicate potentially aberrant semen characteristics, getting a semen analysis is always preferred to help inform treatment decisions. Testicular volume difference is superseded by a normal semen study, which supports an observational method[35].

The current best indicator of testicular damage is a volume differential of more than 2 milliliters, as determined by ultrasonography. This should be the minimum condition for surgical repair of the teenage varicocele[7]. However, the literature lacks the test to differentiate between teenagers with varicocele who will become infertile and those who will remain fertile.

THE CURRENT CONSENSUS ON MANAGEMENT AND SURGICAL INTERVENTION

Surgical management

Multiple techniques for surgical repair of varicocele have been described and studied; however, the approach is at the surgeon's discretion. The methods include subinguinal (Marmar), inguinal (Ivanissevitch), abdominal retroperitoneal (Palomo), and microsurgical methods, as well as transperitoneal or retroperitoneal approaches by laparoscopy[7,35]. The gold standard for the surgical treatment of varicocele in adult patients appears to be the microsurgical (Goldstein's) subinguinal technique[35-37]. In a landmark study, Abdel-Meguid et al[38] found that males with palpable varicoceles had significantly higher rates of natural conception following microsurgical varicocelectomy compared to those who underwent observation (32.9% vs 13.9%). The subinguinal (Marmar) approach and a lymphatic-sparing (modified Palomo) approach have low complication and recurrence rates[39-41]. A similar growth of testicular catch-up was seen with all open-surgical techniques. Thus, it is evident that insufficient data exist to establish which method is more effective for this age range. The long-term implications of minimally invasive approaches, such as laparoscopic varicocele ligation, in children are uncertain[35]. Although it has a higher learning curve, microsurgical subinguinal varicocelectomy gives the lowest rates of recurrence and complications when compared to other surgical methods for varicocele. Although laparoscopic procedures are associated with faster recovery and shorter operating times, they may also have a higher recurrence rate. Despite their effectiveness, open surgical techniques are associated with more postoperative pain and more extended hospital stays. In terms of safety and efficacy, laparoscopic varicocelectomy is less effective than microsurgical varicocelectomy[42].

Current recommendations stress the value of tailored treatment strategies for teenage varicocele, taking into account variables such as TVD and semen analysis findings[43]. Similarly, although scrotal ultrasonography improves diagnostic precision, it might not be financially advantageous to perform routinely on all adolescents with varicocele. To maximize resource use, targeted ultrasonography evaluations are recommended in situations where physical examinations are ambiguous or when there is significant testicular asymmetry.

A meta-analysis comparing outcomes for different surgical techniques revealed that the recurrence rate is higher with embolization and sclerotherapy procedures, ranging from 2.1% to 7.6%. The postoperative hydrocele rate is higher with the laparoscopic mass-ligation/division approach, ranging from 0.8% to 11.4%. There have been no reports of testicular atrophy following laparoscopic or embolization/sclerotherapy procedures. Approximately 10% of cases of technical failure (inability to complete the treatment) are associated with the use of the retrograde embolization technique. Testicular atrophy has not been reported, and the laparoscopic lymphatic-sparing technique has the lowest recurrence rate, as well as the lowest incidence of hydrocele and other complications[44].

Non-surgical therapy

Percutaneous antegrade sclerotherapy and vascular ablation/embolization are non-surgical adjunctive treatment options for varicocele. Percutaneous embolization emerges as a minimally invasive alternative to surgery for AV. Although recurrence is more frequent with embolization or sclerotherapy operations, testicular atrophy was not seen in any of them[45]. These techniques have been reported to have rare complications, including contrast reactions and migration of embolization devices. However, recent advancements in percutaneous embolization and sclerotherapy, particularly in the teenage population, have shown improved outcomes, as reported by Storm et al[46]. Based on testicular asymmetry, semen parameters, and symptomatology, management strategies range from conservative surveillance to surgical varicocelectomy and minimally invasive procedures like embolization.

SUBGROUPS OF AV THAT BENEFIT FROM SURGICAL INTERVENTION

Diamond et al[22] concluded that measuring testicular volume by US revealed that asymmetry of greater than 10% between normal and affected testes correlated with a significantly decreased sperm concentration and total motile sperm count. Hypogonadism has been reported in adolescent boys with varicocele, and its repair helps in improving the mean serum testosterone levels (increasing mean values from 319 ng/dL to 409 ng/dL)[47]. Testicular catch-up volume is the most crucial metric to assess varicocelectomy results. Catch-up growth of testes has been documented among 60%-90% of teenagers with preoperative asymmetry following varicocelectomy, according to multiple studies[25]. Therefore, the boys in the subgroup who have abnormal semen parameters and testicular volume asymmetries are the ones who benefit from surgery.

The association of varicocele with altered semen parameters like a decrease in sperm density, motility, and normal morphology is well documented in multiple studies. Significant increases in sperm motility and density were noted in males with varicocele who received treatment, according to studies that included 379 treated and 270 untreated men. All these findings point towards the consequences of varicocele on fertility in adults and young men, as well as comparable therapeutic benefits in these sub-groups of patients[48].

Çayan et al[49], in their study, included 408 boys with clinically palpable varicocele, aged between 12 years and 19 years, and observed the paternity rates following surgery and conservative management. Of these, 286 boys were subjected to microsurgical inguinal or subinguinal varicocelectomy, and 122 boys were observed without surgery (control group). This study suggested that early treatment should be taken into consideration when sperm parameters show signs of decline, low blood testosterone, or elevated serum FSH levels. The microsurgical varicocelectomy group had a paternity rate of 77.3% compared to 48.4% in the control group (P < 0.005, odds ratio: 3.63). The time to conception in the varicocele treatment group was significantly less than the control group (11.18 ± 6.5 months vs 16.85 ± 6.9 months, respectively) (P < 0.005)[49].

A meta-analysis and systematic review of the treatment of varicocele in children, which included 12 randomized controlled trials, 47 non-randomized comparative studies, and 38 case series, was conducted in 2018 by Silay et al[2]. They concluded that varicocele repair leads to a significant improvement in semen parameters and testicular volume. No surgical technique has been shown to offer superior results in improving sperm parameters and testicular catch-up growth[2]. The most common complication was the formation of a hydrocele. Lymphatic and artery-sparing surgery had less hydrocele formation when compared with non-sparing techniques. The lowest rates of hydrocele development (0.44%) and recurrence (1.05%) have been noted with the microsurgical subinguinal technique[32].

There is considerable global heterogeneity in the management approaches for teenage varicocele. Adolescents who exhibit significant testicular asymmetry or aberrant semen characteristics are often candidates for surgical intervention in North America and Europe. This strategy is based on recommendations made by professional associations, including the EAU, the American Urological Association, and the American Society for Reproductive Medicine. On the other hand, a lot of Asian nations take a more cautious approach, saving surgery for patients who show signs of growing testicular shrinkage or ongoing complaints. These geographical variations were highlighted by an extensive worldwide survey that included 574 professionals from 59 different countries. The study also revealed a wide range of perspectives on varicocele diagnosis, indications for repair, and care strategies[50]. Notably, a significant proportion of responses deviated from established guidelines, underscoring the need for further studies and consensus in the management of AV.

LONG-TERM EFFECTS OF AN UNTREATED AV

Spontaneous catch-up growth of affected testicles has been reported with expectant follow-up of adolescent boys with varicocele. Kolon et al[51] evaluated 71 boys with varicocele, of which 38 (54%) had testicular asymmetry of more than 15%. In a two-year follow-up without surgery, 27 boys showed improvement, and only 11 boys remained affected by testicular asymmetry of more than 15%. Similarly, multiple studies have suggested patients with testicular asymmetry < 20% have shown spontaneous catch-up growth and can be followed up[30].

Van Batavia et al[52] demonstrated that expectant management in adolescent boys with varicocele and testicular asymmetry of > 20% and a PRF of 38 cm/second did not show catch-up growth, and they favored intervention. Improved testicular growth and function have been noted with early intervention in cases of teenage varicocele, especially before noticeable testicular asymmetry appears. Irreversible testicular injury and reduced reproductive potential could result from postponing therapy[25]. Hence, due to a diverse natural history of untreated AV, follow-up monitoring with objective measurement of testicular size and/or semen analysis every year should be made available to adolescents with varicocele having normal size of ipsilateral testicles. Although testicular catch-up development can result from both conservative and surgical management, long-term follow-up studies suggest that surgical intervention may provide better results in terms of testicular catch-up growth and lower recurrence rates[53]. Figure 1 summarizes the algorithm for evaluation and management of AV[1,7,17,23,25,27,28,31-37,42,47,51].

Figure 1 Algorithm for evaluation and management of adolescent varicocele. ESPU: European Society for Paediatric Urology; FSH: Follicle-stimulating hormone; LH: Luteinizing hormone.

The long-term impact on testicular function and ultimate fertility potential makes the asymptomatic left AV more significant. If unrecognised or left untreated, it leads to atrophy of the testicles, reduced hormone production, impaired spermatogenesis, and may lead to primary infertility in some cases, even without producing any noticeable symptoms. Additionally, asymptomatic varicoceles often progress silently, with clinical signs appearing much later in life; by then, irreversible damage to the testicles may have already occurred.

An intervention significantly preserves testicular volume, thereby safeguarding the individual's future fertility potential[2]. Moreover, the psychological trauma that one undergoes is greatly minimized if diagnosed and treated early in life. Thus, prioritizing the management of asymptomatic AVs in those at risk is crucial for preserving their reproductive potential. Figure 2 illustrates the algorithm for the evaluation and management of Asymptomatic Unilateral Left Varicocele[1,7,17,23,27,28,31-33,35-37,42,47,51]. It provides a detailed illustration of the various modes of intervention required for varicocele grades, including clinical palpability, testicular asymmetry, the extent of hormonal and seminal parameter abnormalities, and Doppler findings.

Figure 2  Algorithm for evaluation and management of asymptomatic unilateral left adolescent varicocele.

PSYCHOSOMATIC ISSUES RELATED TO UNTREATED AV

To label an adolescent as subfertile has a substantial psychological impact. Semen analysis forms a direct indicator for the fertility assessment. However, requesting a semen sample from an adolescent boy causes discomfort for both the parent and the individual. In adolescent populations, obtaining trustworthy semen samples poses logistical, psychological, and ethical difficulties. Cultural sensitivities, pain with the process, and a lack of established guidelines are some of the factors that make it difficult and frequently result in this age group using semen analysis less frequently. In a survey conducted by Fine et al[54] to evaluate the management of teenage varicoceles, only 13.7% of physicians included semen analysis in their routine evaluation, and 43% of practitioners never requested semen analysis. The most common reason for excluding semen analysis in evaluation is a lack of knowledge and awareness. Appropriate counselling by the urologist to obtain semen samples provides a more direct prognostication of the fertility status. Awareness will motivate compliance with sequential testing and comprehensive follow-up, thereby aiding in planning further treatment modes.

Teens with untreated varicocele may grow more conscious of the possible effects on their future masculinity and fertility, which can lead to feelings of inadequacy, anxiety, and despair. The prevalence of these "negative" psychological issues ranged from 28.6% to 36.4% among students attending school or college[55]. In addition, the physical manifestations of varicocele, such as chronic testicular pain, swelling, and visible veins, can also lead to significant psychological distress[56]. These physical symptoms may contribute to low self-esteem, poor academic performance, and disruption of social activities, further exacerbating the psychosomatic implications of the condition[57]. Al-Rawashdah et al[58] investigated the psychological and emotional experiences of patients having microsurgical varicocelectomy in a qualitative study. As adolescents with varicocele may have psychological difficulties in addition to physical symptoms, such as worries about body image and fertility, addressing these factors with guidance, treatment satisfaction, and general quality of life can be enhanced. Providing a proper explanation of the condition to patients and their parents, along with appropriate counselling, would be of great help in mitigating these psychosomatic issues[58]. To meet the complex demands of adolescents with varicocele, a multidisciplinary care paradigm combining urologists, psychologists, and primary care physicians is advised.

SEMEN PARAMETERS POST-VARICOCELECTOMY

To ascertain whether surgical intervention can enhance reproductive results, studies have examined the impacts of early varicocelectomy on teenage semen analysis reports and sperm parameters. Lenzi et al[59] evaluated semen parameters, such as sperm concentration, motility, and morphology, between 19 patients who had early varicocelectomy in their teens and two control groups, which consisted of untreated varicocele patients and healthy age-matched persons. Analysis of semen was done two to eight years after surgery. According to the study, the sperm motility and morphology of teens were enhanced with early varicocelectomy. Reduced sperm concentration, however, remained, suggesting that although surgery can help with specific semen parameters, it would not be able to completely undo the long-term consequences of varicocele on male fertility[59].

In a study by Shebl and Sabry[60], 47 patients with an average age of 17.4 ± 1.5 years who underwent microsurgical varicocelectomy were evaluated. Six months after the procedure, semen analysis revealed a significant improvement in sperm volume, increasing from 2.5 mL to 3.2 mL (P < 0.001). Additionally, sperm motility and vitality significantly improved, and the sperm count increased from 10.8 million to 20.3 million (P < 0.001). Abnormalities in sperm morphology have considerably decreased, and progressive sperm movement has risen from 35% to 59% (P < 0.001)[60]. Following surgery, testicular volume also grew noticeably. In adolescents with previous altered semen analysis reports, varicocelectomy has demonstrated a significant improvement in the semen parameters.

SOCIOECONOMIC ASPECT AND RISK FACTORS

Socioeconomic disparities play a crucial role in how AV is diagnosed and managed. In areas with limited healthcare resources, adolescents may face barriers to timely diagnosis and appropriate treatment. Due to financial limitations, only 81 of the 149 adolescents with a clinical diagnosis of varicocele in Benin research had a scrotal US. According to the study, testicular hypotrophy, a common side effect of varicocele, can be detected more accurately with ultrasonography than with a clinical examination alone[61]. In particular, testicular hypotrophy was found in 20.99% of adolescents by clinical evaluation, while it was found in 39.5% of adolescents on ultrasonography. This demonstrates how socioeconomic circumstances and a lack of healthcare resources can result in underdiagnosis and treatment delays, which may worsen the consequences for the reproductive health of impacted teenagers. Such delays can have lasting consequences, potentially affecting their future reproductive health and overall quality of life[10].

Adolescents with untreated varicocele can become infertile and require assisted reproductive technologies (ART) as adults. As a cost-effective method that can restore natural fertility and, in certain situations, lessen or eliminate the need for ART, varicocele repair has gained popularity due to the increasing incidence and financial burden of infertility. Preoperative varicocele repair has been demonstrated to increase live birth rates even when ART is necessary, minimizing the need for several cycles and related expenses. Timely intervention is crucial due to the potential psychological discomfort and the financial burden associated with ART[62].

TAKE HOME POINTS

The incidence of varicocele in adolescence is as common as in adults and increases with age. Adolescents with varicocele that produce testicular volume asymmetry and sperm parameter abnormality are at risk of future subfertility and are the ones who most benefit from surgery. Boys with varicocele who do not meet the surgical indications should be counselled for annual follow-up, preferably with a semen analysis. Microsurgical varicocelectomy offers good catch-up growth and improvement in sperm parameters with the least reported complication.

CONCLUSION

AV, though mostly asymptomatic, if left untreated, leads to a significant impairment of testicular growth, oligospermia, and may lead to long-term infertility. A high index of suspicion guided by a thorough clinical examination, early diagnosis supported by Doppler US findings, and semen analysis followed by appropriate intervention are the key elements to prevent irreversible testicular damage. Surgical repair, particularly the subinguinal microsurgical varicocelectomy, has shown significant improvement in fertility potential. Proactive measures are essential not only for individuals at risk in safeguarding their fertility potential but also in reducing the psychological distress associated with a reduction in masculinity. Prioritizing evaluation in all adolescents with varicocele, including those who are asymptomatic, is important to identify individuals at risk of testicular damage. In selected cases, intervention may help preserve testicular health and overall well-being.