The significance of elevated scrotal temperature in an adolescent with a varicocele

The dilemma of adolescent varicocele

Adolescent varicocele is associated with ipsilateral testicular hypotrophy and the concern for future infertility. A testicular size discrepancy greater than 15-20 % between left and right testicle is an indication for treatment to allow catch-up growth in the hope of preventing a future decline in fertility. Some authors advocate for a period of watchful waiting, as normal testicular growth may occur asymmetrically. We review the current literature to highlight some controversies and challenges in management.

Adolescent varicocoele management controversies

Varicocoele is defined as excessive dilatation of the pampiniform venous plexus of the spermatic cord. Varicocoele frequently appears during early puberty and is recognized to be the most common surgically correctable cause of male infertility. However, the actual incidence in adolescents, pathophysiology and the association with male factor infertility all remain somewhat controversial. The most accurate diagnostic technique for identifying young men who will benefit from surgical treatment has yet to be established. Observations of testicular asymmetry and deteriorating semen quality helped establish current guidelines and recommendations for surgical treatment. Further studies, comparing observation with surgical intervention, are needed to refine the current indications for varicocoele repair in the adolescent male.

Insight into oxidative stress in varicocele-associated male infertility: part 1

Varicocele is recognized as the leading cause of male infertility because it can impair spermatogenesis through several distinct pathophysiological mechanisms. Current evidence supports oxidative stress as a key element in the pathophysiology of varicocele-related infertility, although these mechanisms have not yet been fully described. Measurement of the reactive oxygen species and other markers of oxidative stress, including the levels of the antioxidant enzymes catalase and superoxide dismutase, can provide valuable information on the extent of oxidative stress and might guide therapeutic management strategies. The testis can respond to varicocele-associated cell stressors, such as heat stress, ischaemia or production of vasodilators (for example, nitric oxide) at the expense of the generation of excessive reactive oxygen species. These responses have their own implications in exacerbating the underlying oxidative stress and on the subsequent infertility.

A single, mild, transient scrotal heat stress causes DNA damage, subfertility and impairs formation of blastocysts in mice

Infertility represents a major clinical problem and 50% of cases are attributable to the male partner. Testicular function is temperature dependent, and in both man and mouse the position of the testes in the scrotum ensures that they are kept at between 2 and 8 °C below core body temperature. We used a mouse model to investigate the impact of a single, transient, mild, scrotal heat stress (38, 40 or 42 °C for 30 min) on testicular function, sperm DNA integrity and embryo survival. We detected temperature-dependent changes in testicular architecture, number of apoptotic cells and a significant reduction in testis weight 7 and 14 days after heat stress at 42 °C. We report for the first time that DNA strand breaks (γ-H2AX-positive foci) were present in spermatocytes recovered from testes subjected to 40 or 42 °C. Fertility of heat-stressed males was tested 23–28 d after treatment (sperm at this time would have been spermatocytes at time of heating). Paternal heat stress at 42 °C resulted in reduced pregnancy rate, placental weight and litter size; pregnancies from the 40 °C group had increased resorptions at e14.5. Abnormalities in embryonic development were detected at e3.5 andin vitrofertilisation with sperm recovered 16 h or 23 d after scrotal stress at 42 °C revealed a block in development between the 4-cell and blastocyst stages. This study has provided evidence of temperature-dependent effects on germ cell DNA integrity and highlighted the importance of an intact paternal genome for normal embryo development.

Varicocele in adolescence induces left and right testicular volume loss

OBJECTIVE

To determine the effect of a palpable left-sided varicocele (which in adolescent patients can adversely affect left testicular volume) on right testicular volume with progressive Tanner development and increasing varicocele grade.

PATIENTS AND METHODS

The right and left testicular volumes were measured with a standard orchidometer in 70 control patients (mean age 14.6 years, SD 2.2) with no palpable testicular abnormality and in 434 (mean age 14.3 years, SD 2.3) with a palpable left-sided varicocele. Patients with bilateral and right-sided varicoceles were excluded from the study.

RESULTS

There was no significant difference between the left and right testicular volumes in the control patients. The testicular volumes of patients with a grade I varicocele were similar to those in control patients. Patients with a grade II varicocele had a significantly smaller left testis than the controls at Tanner stages 4 and 5 (P < or = 0.05). Patients with a grade III varicocele had a significantly smaller left testis than controls at each Tanner stage (P < or = 0.05) and significantly smaller right testis than controls at Tanner stages 4 and 5 (P < or = 0.05).

CONCLUSION

The presence of a grade I varicocele in adolescence appears to have no effect on normal testicular growth. Some patients with a grade II varicocele are at risk of left testicular volume loss with time and should have their testicular volume measured annually. Patients with grade III varicocele are at risk of bilateral testicular volume loss; a careful evaluation and early surgical intervention are recommended in this group of patients.