Left varicocele at puberty

Does total testicular volume predict testicular volume difference in adolescent males with varicocele?

Introduction:

We evaluated the relationship between total testicular volume (TTV) and testicular volume differential (TVD) in adolescent males with varicocele. Both low TTV and high TVD have been independently associated with higher incidences of infertility later in life, but a predictive relationship between TTV and TVD directly has yet to be described.

Materials and Methods:

We retrospectively analyzed a database of Tanner 5 boys ages 16-21 who presented with varicocele at a single institution between 2009 and 2017. All patients had a scrotal sonogram prior to surgical intervention. TTV and TVD were calculated for each individual and four non-exclusive groupings of patients were created for statistical analysis. We chose 30 cc as a cut off value for low TTV based on prior studies.

Results:

209 patients met our inclusion criteria. Mean age was 18.3 years (16–21, SD 1.7) with a mean total testicular volume of 36 cc (13.5-78.2, SD 11.1). Cut off points of TVD of 20% and TTV of 30 cc were used to separate patients. There were 65 boys (31%) with TTV < 30 cc and 58 boys (28%) with TVD ≥ 20%. Among males with TTV < 30 cc, 23 (35%) had a TVD ≥ 20%. Among males with TTV ≥ 30 cc, 35 (24%) had a TVD ≥ 20%. The relationship between TVD and TTV was found to be non-significant (p > 0.05).

Discussion:

Adolescent varicoceles continue to pose a challenge to pediatric urologists. The dilemma of over-aggressive treatment has proven difficult to balance with the risk of infertility. We hoped that elucidating the relationship between TTV and TVD could be useful in identifying patients who are at greater risk for infertility while decreasing the need for more intrusive testing, such as semen analysis, in an adolescent population. We looked at the direct relationship between low TTV and high TVD. In our population, there was a non-significant relationship between TTV < 30 cc and TVD ≥ 20% (p > 0.05) indicating that in adolescents with varicocele, TTV and TVD are independent variables. Our study limitations include the inherent user dependent bias of ultrasound measurements and data collection at a single institution with high ethnic diversity, possibly not comparable to all patient populations.

Conclusions:

Low TTV (< 30 cc) itself is not predictive of high TVD (≥ 20%) in adolescent boys with varicocele, despite their reported independent associations with impaired fertility in other studies.

Effect of selenium on testicular damage induced by varicocele in adult male Wistar rats

PROJECT

Varicocele is an abnormal tortuosity and distension of the veins of the pampiniform plexus in the spermatic cord. It is the most common surgically correctable cause of male infertility. Several studies have revealed the effects of increased oxidative stress on serum, semen, and testicular tissues in patients with varicocele or in animal models. The aim of this study was to investigate the effects of sodium selenite on testicular damage induced by experimental left varicocele in male Wistar rats.

PROCEDURE

In the present study, the effects of oral administration of sodium selenite (at doses of 0.05, 0.1, 0.2, and 0.4mg/kg bw) were assessed in normal and varicocelized rats.

RESULTS

The varicocelized control rats showed decrease in sperm quality parameters, decreased activity of testes CAT, GPX and SOD, increased levels of MDA, and damage in testicular architecture. Administration of sodium selenite significantly reduced these changes to nearly normal levels, but did not change these parameters in normal rats. Histopathological studies further confirmed the protective effects of sodium selenite on varicocele-induced testicular damage in rats. Administrations of sodium selenite did not change these parameters in normal rats.

CONCLUSIONS

Taken together, the results of this study suggest that sodium selenite treatment may have beneficial effect on the testes of varicocelized rats.

Perspectives in Pediatric Pathology, Chapter 20. Adolescent Varicocele

Varicocele is characterized by elongation, dilatation, and tortuosity of the veins draining the testis and its covers, causing circulatory reflux along the inner spermatic vein [ 1 ]. Varicocele results in progressive testicular lesions and, if untreated, can lead to testicular atrophy [ 2 ]. Varicocele is considered the most frequently identified cause of male infertility [ 3 ]. The mechanisms involved in varicocele formation are not well known and probably are multiple, differing from one patient to another.

Ipsilateral testicular catch-up growth rate following microsurgical inguinal adolescent varicocelectomy

Objective. To evaluate the ipsilateral catch-up growth rates compared to contralateral testicular growth in adolescents with varicocele undergoing microsurgical inguinal varicocelectomy. Materials and Methods. Between December 2005 and May 2007, 39 adolescent patients with grade 2-3 varicocele admitted to our clinic with complaints of pain and/or testicular asymmetry were operated. Preoperative mean age was 14.5 ± 1.96 (9–17). Testicular volumes were assessed with ultrasound every 3 months. The available followup was 39 months. Results. In our series, mean testicular preoperative volumes were 9.07 ± 3.19 mL for the right and 5.90 ± 1.74 mL for the left. Mean testicular volumes at the end of follow up were 13.97 ± 3.42 mL for the right and 12.20 ± 4.05 mL for the left. The testicular catch-up growth approximately begins after the 9th month and significant catch-up occurred in the 12–24 months (P < 0.05). Conclusion. Since testicular volume is the primary method of assessing testicular function in adolescents, testicular size can predict future fertility status significantly 9 months after surgical varicocele correction.

The complex structure of the smooth muscle layer of spermatic veins and its potential role in the development of varicocele testis

OBJECTIVES

Varicocele, a dilatation of the pampiniform venous plexus, is considered to cause male infertility. The exact mechanism of varicocele development is not clarified yet. This study focused on the structure of varicocele veins, compared with normal spermatic veins, and its potential role in varicocele development.

METHODS

Morphologic and immunohistochemical studies using antibodies against vWF and neurofilament-200 (NF-200) were performed on spermatic vein fragments of 20 varicocele patients and 40 normal spermatic cords. Casting preparation of veins was performed on five normal spermatic cords.

RESULTS

Casting preparation frequently revealed circular constrictions of normal spermatic vein lumina. Histologic evaluation showed a strong longitudinal smooth muscle layer in the adventitia of large veins in addition to the circularly organised tunica media. Serial sections showed smooth muscle fibres branching from the outer longitudinal into the inner circular layer. Immunostaining for vWF revealed high vascularisation of this outer layer. Interestingly, the number of nerve fibres marked by NF-200 immunostaining was considerably higher in large veins compared to the testicular artery. The longitudinal smooth muscle layer was significantly degraded in the presence of varicocele grades I and II, and did not even exist in varicocele grade III. Correspondingly, the number of vasa vasorum and nerve fibres was reduced in varicocele veins.

CONCLUSIONS

Our data show a complex smooth muscle organisation of spermatic veins, which serves the basis for a contractile mechanism, providing an effective blood transport through pampiniform plexus. This mechanism is obviously damaged in the varicocele. Molecular processes behind this impairment remain to be clarified.

Adolescent varicocele: association with somatometric parameters

INTRODUCTION

The developmental changes that occur as a result of puberty have been hypothesized to be important causes of varicocele. Various somatometric parameters were known to affect the occurrence of varicocele during the growth period. We conducted this study in order to examine these relationships and to determine the incidence of varicocele in adolescent males.

PATIENTS AND METHODS

We evaluated 1,200 healthy males aged 0-19 years for varicocele and correlated it with the following somatometric parameters: age, height, body mass index (BMI), pubic hair distribution, penile length and testicular volume.

RESULTS

Adolescent varicocele was found in 5.6% of the participants. The 13- to 19-year age-group had the highest incidence of varicocele (10.5%). Logistic regression analysis showed that the incidence was positively correlated with age, height and penile length (odds ratio 1.61, 1.04 and 1.37, respectively) and negatively correlated with left testicular volume, BMI and pubic hair distribution (odds ratio 0.87, 0.87 and 0.47, respectively).

CONCLUSION

Varicocele was more prevalent in tall boys with a lower BMI, who had quickly progressed through puberty. Our observations suggest that varicocele is associated with various somatometric parameters.

"Scrotal varicocele, exclude a renal tumour". Is this evidence based?

A scrotal varicocele is a common finding during both a scrotal clinical examination or during the course of a scrotal ultrasound examination and invariably found in the left hemiscrotum. Traditionally when a scrotal varicocele is found, the referring clinician requests a renal ultrasound examination or the sonographer extends the examination to include a renal examination; to exclude a retroperitoneal or renal tumour as the cause for the varicocele. The present article examines the relevance of performing the extended ultrasound examination by reviewing the pathophysiological pathways for the development of a varicocele in the presence of a renal or retroperitoneal tumour; the prevalance of co-existing renal or retroperitoneal tumours and a varicocele; and the male population in whom this extended examination may be necessary. The conclusion from available evidence suggests that a retroperitoneal tumour will manifest in other ways before the development of a varicocele, the young patient with a varicocele will almost never have a retroperitoneal tumour, and only when a varicocele develops in an older patient will an extended examination be relevant. Even then it will be a rare finding and there will be other clinical manifestations of the primary tumour.

Varicocele in schoolboys

This study was conducted to examine the effect of height and weight on the incidence of varicocele in schoolboys aged 5-16 years and the impact of varicocele on testicular size. Genital stage, height, weight, varicocele grade, and testicular size were recorded for 3047 school boys who were clinically examined while standing by a specialist in urology. Left varicocele was detected in 98 of the boys who were all aged 9-16 years. The mean weight of boys with and without varicocele was 42 kg (95% confidence interval [CI] 40-44 kg) and 47 (95% CI 47-47 kg), respectively (p =.00). There was no difference in mean height between the two groups nor in left and right testicular volume. Although 6 boys with varicocele had a left testicular volume > or =2 mL less than right, there were also 7 boys of comparable age who had a left testicular volume > or =2 mL larger than right. The incidence of varicocele in Greek adolescents is low. Boys with varicocele weighed significantly less but there were no significant differences in height or left versus right testicular volumes. In the light of these observations, the use of left testicular hypotrophy (> or =2 mL compared with the right testicle) should be reconsidered as an indicator for varicocele-induced damage of the testicle in this age group.

The prevalence of varicocele and varicocele-related testicular atrophy in Turkish children and adolescents

OBJECTIVE

To determine the prevalence and site of varicocele and varicocele-related testicular atrophy in children and adolescents.

PATIENTS AND METHODS

The study included 4052 boys aged of 2-19 years, divided into four age groups; the findings of a physical examination, any testicular atrophy and testicular volume were recorded.

RESULTS

Varicocele was detected in 293 (7.2%) of the 4052 boys; the prevalence was 0.79% in those aged 2-6 years, 0.96% at 7-10 years, 7.8% at 11-14 years and 14.1% at 15-19 years. The prevalence was 0.92% in 1232 children aged 2-10 years and 11.0% in 2531 adolescents aged 11-19 years (P < 0.001). The prevalence increased significantly at age 13 years (P < 0.005). The varicocele was unilateral in 263 of the 293 (89.7%) boys with varicocele; of these, one (0.38%) was on the right and the others on the left side. Varicoceles were bilateral in 30 of 279 boys (10.8%) aged 11-19 years but none were detected in those aged < 11 years. Varicocele-related testicular atrophy was not present in those aged < 11 years, but seven boys (7.3%) aged 11-14 years and 17 (9.3%) aged 15-19 years had testicular atrophy. The difference in prevalence between the last two age groups with atrophy was not significant.

CONCLUSION

These findings support the view that varicocele is a progressive disease and that the prevalence of varicocele and testicular atrophy increases with the puberty.

Ultrastructural and immunohistochemical study of basal lamina of the testis in adolescent varicocele

OBJECTIVE

To evaluate a possible involvement of the extracellular matrix (ECM) in the testes of adolescents with varicocele.

DESIGN

Cross-sectional study.

SETTING

University-based medical center.

PATIENT(S)

Twenty-four adolescents aged between 13 and 18 years underwent surgical treatment for repair of left idiopathic varicocele.

INTERVENTION

A testis biopsy was performed at time of surgery.

MAIN OUTCOME MEASURE(S)

Transmission electron microscopy study of basal lamina and immunofluorescence studies of collagen type IV and laminin, two major components of basal lamina.

RESULT(S)

Transmission electron microscopy observations showed an uneven profile of the basal lamina with a variable thickness. Immunofluorescence studies showed an irregular immunofluorescent line that appeared interrupted in some observations. Collagen type IV showed some areas of strong immunostaining with other areas with reduced immunoreactivity.

CONCLUSION(S)

Our ultrastructural and immunohistochemical observations highlight focal damage at the level of peritubular basal lamina, but this damage is not as severe as that described in adult varicocele. Initial involvement of basal lamina could represent one of the mechanisms responsible for varicocele-induced histologic alterations of the testes.

Varicocele: a multidisciplinary approach in children and adolescents

PURPOSE

To minimize varicocele treatment in children and adolescents a multidisciplinary approach that includes surgery and operative radiology has been used at our institution since 1991. We present our results during this 7-year period.

MATERIALS AND METHODS

From January 1991 to December 1997 we examined 477 patients 4 years 5 months to 25 years 4 months old (mean age 13 years 3 months) with varicocele, of whom 367 (396 varicoceles) required treatment. Percutaneous sclero-embolization was suggested as the primary treatment of choice in all cases, while surgery was reserved for select cases. A total of 366 cases followed at least 6 months (mean 1 year) were entered into this study.

RESULTS

Only 7.1% of the patients or families preferred surgery. In 47 patients sclero-embolization was not possible due to technical problems or vascular anomalies. Sclero-embolization was successful in 79.4% of 277 patients, and retroperitoneal ligation was successful in 88.7% of 124. Since 1995 ligation of the whole spermatic bundle above the vas deferens has been preferred, and only 1 recurrence has been observed in 60 cases.

CONCLUSIONS

Percutaneous sclero-embolization is a minimally invasive treatment of varicocele that is feasible in children and adolescents. Most patients prefer this therapy, although it is not as safe as surgery. When open surgery is required, complete ligation of the whole vascular pedicle above the vas deferens offers excellent success.

A morphometric and ultrastructural study of the changes in the lamina propria in adolescents with varicocele

OBJECTIVE

To verify if changes in the lamina propria and its components, reported in adults with varicocele, are already present in adolescents with idiopathic varicocele, using a morphometric and ultrastructural study.

MATERIALS AND METHODS

Twenty testicular biopsies from adolescents (mean age 15.6 years) were obtained during surgery for left idiopathic varicocele; five testicular biopsies from adolescents (mean age 16 years) undergoing surgery for hydrocele or inguinal hernia were used as controls. Biopsy specimens were processed for light and transmission electron microscopy; the sections were evaluated morphometrically using computerized image analysis.

RESULTS

Morphometric and ultrastructural examination of the testes with varicocele showed an increased thickness in the lamina propria, caused principally by an increase in the extracellular matrix components, and deep invaginations towards the germinal epithelium.

CONCLUSION

There is detectable damage of the lamina propria in adolescents affected by left idiopathic varicocele, although not as well developed or as severe as in adults.

Assessment of adolescent varicocele

Varicocele is the most important male factor responsible for decreased fertility potential in married couples. From March through June 1994, 2,470 school boys aged 10-20 years were examined to establish the incidence of consecutive grades of varicocele and to develop a protocol for diagnosis and treatment of adolescents with varicocele. Grade 1 varicocele was found in 18%, grade 2 in 12%, and grade 3 in 5% of the population examined. An original protocol of ultrasonographic (US) examination (previously verified by angioscintigraphy) was introduced to assess boys with clinically diagnosed varicocele. The volume of each testis, testicular volume decrease (TVD), pampiniform vein diameter (PVD), and basal (BBF) and maximum blood flow (MBF) velocities were measured in 625 boys. In 74 cases a semen analysis was performed. The statistical analysis revealed that the presence of venous reflux and PVD correlated with the grade of varicocele. Decreases in testicular volume were highly dependent on the grade of varicocele, PVD, and BBF and MBF velocities. Analysis of the relationship between spermatic (boys over 17 years) and US findings revealed that the quality of spermatogenesis can be predicted by US examination in adolescents with varicocele. The authors recommend multiparametric US examination as a reliable, objective, and repeatable technique for establishing criteria for operative treatment in boys under 18 years of age with varicocele as well as for postoperative evaluation.

Percutaneous venography and embolization of the internal spermatic vein by spring coil for treatment of the left varicocele in children

The treatment of varicocele is controversial in boys and it is a contributing factor to male infertility. Recently it has been proposed that early therapy of a varicocele during childhood or adolescence may improve the prognosis of fertility. The authors review their experience with the diagnosis and management of left varicocele in 20 pediatric patients 6 to 15 years old. All were managed under local anesthesia by spermatic venography and percutaneous transcatheter embolization of the internal spermatic vein with spring coils. All achieved satisfactory occlusion, and during the follow-up, from 13 years to 9 months, there was only one recurrence, noted in a patient 6 months after the procedure. Complications were phlebitis of the pampiniform plexus, leading to swelling and erythema of the left scrotum, and mild flank pain; these symptoms resolved without sequelae. This is a safe and effective nonsurgical method of obliterating varicoceles in children, with a low morbidity rate and a short hospital stay.

Varicocele related testicular atrophy and its predictive effect upon fertility

Varicoceles are the most common reversible cause of male factor infertility, yet approximately 80% of men with varicoceles are fertile. Therefore, it is unclear whether all adolescents should undergo prophylactic varicocelectomy to prevent future infertility or whether a subgroup of patients who are at increased risk for future infertility can be identified and treated. Testicular size discrepancy or hypotrophy of the testis associated with a unilateral varicocele has been suggested as an indication for prophylactic varicocelectomy in adolescents. We examined 946 men attending a urological clinic for complaints other than infertility to determine whether testis size discrepancy was predictive of infertility in men with left varicoceles. A left varicocele was detected on physical examination in 211 men, of whom 173 (82%) had been able to father children and 38 (18%) had never fathered children. A group of 630 men without palpable varicoceles served as controls, including 528 (84%) with a history of fertility. Testicular size was measured using an orchidometer and the average testicular volume difference was obtained by subtracting left from right testicular volume. The mean testicular volume difference for the fertile men without varicoceles (1.6 +/- 0.3 ml.) was significantly lower than the fertile men with varicoceles (3.1 +/- 0.4 ml.) (p < 0.05) and infertile men with varicoceles (2.5 +/- 0.6 ml.) (p < 0.05). There was no significant difference between fertile and infertile men with varicoceles. This study confirms prior reports that the majority of men with left varicoceles are able to father children and that varicoceles cause significant ipsilateral testicular atrophy/hypotrophy. However, we were unable to demonstrate a correlation between loss of testicular volume and fertility status in men with left varicoceles. Further study is needed to identify the clinical parameters predictive of future infertility in adolescents with varicoceles.

Ligation of the testicular artery and vein in adolescent varicocele

Proper surgical management of adolescent varicocele is controversial. Recent evidence suggests that the Palomo approach gives the best results. We report on the outcomes of 43 consecutive adolescent boys who underwent operative correction of varicocele by a single surgeon from 1979 to 1992. An inguinal approach with ligation of the vascular pedicle above the vas deferens (modified Palomo) was used in each case. From 1979 to 1983 an attempt was made to preserve the testicular artery but it was successful in only 6 of 12 cases. After 1983 no further attempt was made to preserve the artery and, therefore, 37 patients underwent total ligation of the vascular pedicle above the entry of the vas deferens into the spermatic cord. Most of the varicoceles were grade II. Significant discrepancy in testicular volume (10% difference) constituted the main indication for operation. The ipsilateral (left) testis was smaller in 30 of 37 patients (81%). Of those testes with size discrepancy 90% showed significant volume increase following surgery. Many left testes assumed the same volume as the normal right testis. The only surgical failure (recurrence) of the 43 cases occurred in 1 of the 6 in which artery preservation was successful. There were no surgical failures in the group of 37 boys. Mean followup is 3.7 years. Total ligation of the testicular vascular pedicle seems to afford catch-up growth for smaller ipsilateral testes with low risk for recurrence of the varicocele.

Varicoceles: effect on testicular volume in prepubertal and pubertal males

A total of 63 prepubertal and 17 pubertal males were examined to determine both testicular volumes and to correlate testicular volumes with the presence or absence of a varicocele. In the prepubertal group neither the left nor the right testicle predominated in size. In the pubertal group, the left testicle with an associated varicocele was smaller than the right.

Intraoperative spermatic venography during varicocele surgery in adolescents

Intraoperative internal spermatic venography performed immediately following varicocele ligation in the adolescent has been touted as reducing varicocele persistence rates. Previously published data corroborate this statement with low persistence rates. Other series in which venography was not performed report a failure rate of 9 to 30%. During a 5-year period a total of 64 varicocele ligations was performed in 62 male adolescents at our institution. Followup postoperatively revealed an overall varicocele persistence rate of 9%. All patients had intraoperative internal spermatic venography on the affected side. Of 64 venograms 16% had shown collateral drainage that, if not ligated, may have resulted in varicocele persistence. These cases accounted for only 1 of the persistent varicoceles. Additionally, venograms had demonstrated filling of the ipsilateral external iliac vein in 8% of the cases. Despite the fact that no attempt was made to ligate these collaterals, none of these patients had a persistent varicocele. After varicocele ligation 30 of 62 patients were followed long enough to evaluate for testicular catch up growth. Of these 30 patients 24 demonstrated an average relative increase in left testicular volume of 17%. These data support routine intraoperative internal spermatic venography while performing varicocele ligation in the adolescent.

Testis volumes, semen quality, and hormonal patterns in adolescents with and without a varicocele

OBJECTIVE

To study the effects of varicocele on testicular function in adolescents.

DESIGN

A prospective controlled study in 88 randomly selected adolescents.

SETTING

All participants were referred to the fertility outpatient clinic of our University Hospital.

PARTICIPANTS

All participants with a grade II varicocele (group 2) or a grade III varicocele (group 3) were selected at a district military medical council, whereas a similar group of healthy volunteers without a varicocele served as controls (group 3).

INTERVENTIONS

Testis volumes were measured using an orchiometer. Semen analysis was performed according to standard procedures, and serum hormone levels were determined using a radioimmunoassay.

MAIN OUTCOME MEASURE(S)

Testis volumes, semen quality, and hormonal parameters in adolescents with and without a varicocele were compared.

RESULTS

In group 1 (n = 21), the mean left testis volume (24.5 mL; 95% confidence interval [CI]: 22.8 to 26.2) was significantly (P less than 0.05) different from group 2 (n = 15) (20.9 mL: 95% CI: 18.5 to 23.4) and group 3 (n = 52) (20.7 mL; 95% CI: 19.2 to 22.2) (P less than 0.01) adolescents. In adolescents with a pronounced varicocele-associated left testicular growth failure, the total sperm number was reduced. However, sperm concentration, motility, and morphology were not altered. Luteinizing hormone, follicle-stimulating hormone, testosterone, and prolactin levels were all within the normal ranges in the three groups.

CONCLUSIONS

Left testicular growth failure in adolescents with a varicocele is only associated with a decrease in total sperm number.

The effect of post-pubertal varicocele on testicular volume

Paediatric varicocele is a well known entity but its effect on adult infertility has not been adequately clarified. Since measurement of testicular volume is currently the best method of estimating the male reproductive potential, 945 boys aged between 13 and 18 years were examined with regard to testicular volume and the incidence of varicocele. The average volumes for right and left testes were 15.087 +/- 0.237 and 14.514 +/- 0.347 ml respectively, and the incidence of varicocele was 16.7%. The incidence increased from 14.5 to 21.7% as the ages increased from 14 to 18. The differences in volume of the 2 testes in boys with varicocele were statistically significant when compared with the normal group, but this significance failed to become more pronounced when the slight varicocele group (grade I) was included with the normal group and compared with the severe varicocele group (grades II and III). There may be no significant differences between the volumes of the 2 testes in boys with varicocele when careful measurement and strict statistical analyses are applied. However, some boys in the varicocele group were found to have testicular volumes below the confidence interval (mean - SE) or under 1 SD, and the 2 testicular volumes differed in certain age groups. This group requires further follow-up. The results of this study have added further contradictory findings to the issue of paediatric varicocele in terms of testicular atrophy, estimation of potential fertility and the indications for immediate surgery. There is a need for further prospective controlled trials.

The effect of experimental varicocele on the testis of adolescent rats

Experimental varicocele was created by partial ligation of the left renal vein in rats 4, 7 and 12 weeks old to compare the effects of varicocele on the testis at different times of onset: prepuberty, adolescence and adulthood. We examined the testes at 4 and 8 weeks after creation of the varicocele. The experimental groups of rats 4 and 12 weeks old showed slight testicular changes compared to control groups at 4 and 8 weeks postoperatively. In the 7-week group left testicular weight was significantly decreased (1.03 +/- 0.31 gm.) compared to that of the control group (1.51 +/- 0.12 gm.) at 4 weeks. The seminiferous tubular diameter in the left testis also was significantly reduced (219 +/- 37 microns) compared to that of the control group (270 +/- 14 microns). Histological changes, such as degeneration of germinal epithelium, tubular atrophy, Sertoli cell hyperplasia and interstitial edema, were observed more frequently in the 7-week group. At 8 weeks these changes were less significant. Our results suggest that varicocele during adolescence has the most damaging effects on the testis in rats.

Varicocele in youth. A therapeutic dilemma

The need for treatment of asymptomatic varicocele in youth is controversial. In the current study testicular volume and seminal variables were evaluated in three groups: young varicocele patients with undetermined fertility potential, infertile varicocele patients, and a control group of young males. The testicular volume was determined by ultrasonographic measurements. The results revealed a significant loss of "testicular mass" in both varicocele groups compared with the control group. The seminal findings disclosed a severe disturbance of spermatogenesis in the older varicocele group, whereas in the younger varicocele patients only the total spermatic count was significantly depressed. This difference in severity of functional impairment between the younger and older varicocele groups possibly points towards progressiveness of damage to the testicles. A more decisive therapeutic approach to the young male with asymptomatic varicocele and unknown fertility status could be justified.

Diagnosis and surgical correction of the pediatric varicocele

We reviewed our experience with the diagnosis and management of varicoceles in 40 patients 9 to 18 years old. Of the patients 29 underwent varicocelectomy and 11 are being managed conservatively with periodic followup. The results of therapy and criteria for surgical intervention are discussed.

Asymptomatic varicocele in an infant

Varicoceles are a common cause of male infertility. The incidence of varicoceles at puberty is approximately 16 percent, but in prepubertal males, they are rare. We present a case of a varicocele in a 1 1/2-year-old male and discuss whether early recognition and surgical correction may preserve male fertility potential.