Natural history of testicular size in boys with varicoceles

"Management of andrological disorders from childhood and adolescence to transition age: guidelines from the Italian Society of Andrology and Sexual Medicine (SIAMS) in collaboration with the Italian Society for Pediatric Endocrinology and Diabetology (SIEDP)-Part-1"

PURPOSE

Andrological pathologies in the adulthood are often the results of conditions that originate during childhood and adolescence and sometimes even during gestation and neonatal period. Unfortunately, the reports in the literature concerning pediatric andrological diseases are scares and mainly concerning single issues. Furthermore, no shared position statement are so far available.

METHODS

The Italian Society of Andrology and Sexual Medicine (SIAMS) commissioned an expert task force involving the Italian Society of Pediatric Endocrinology and Diabetology (SIEDP) to provide an updated guideline on the diagnosis and management of andrological disorders from childhood and adolescence to transition age. Derived recommendations were based on the grading of recommendations, assessment, development, and evaluation (GRADE) system.

RESULTS

A literature search of articles in English for the term "varicoceles", "gynecomastia", "fertility preservation", "macroorchidism", "precocious puberty" and "pubertal delay" has been performed. Three major aspects for each considered disorder were assessed including diagnosis, clinical management, and treatment. Recommendations and suggestions have been provided for each of the mentioned andrological disorders.

CONCLUSIONS

These are the first guidelines based on a multidisciplinary approach that involves important societies related to the field of andrological medicine from pediatric to transition and adult ages. This fruitful discussion allowed for a general agreement on several recommendations and suggestions to be reached, which can support all stakeholders in improving andrological and general health of the transitional age.

Primary gonadal failure

The term primary gonadal failure encompasses not only testicular insufficiency in 46,XY males and ovarian insufficiency in 46,XX females, but also those disorders of sex development (DSD) which result in gender assignment that is at variance with the genotype and gonadal type. In boys, causes of gonadal failure include Klinefelter and other aneuploidy syndromes, bilateral cryptorchidism, testicular torsion, and forms of 46,XY DSD such as partial androgen insensitivity. Causes in girls include Turner syndrome and other aneuploidies, galactosemia, and autoimmune ovarian failure. Iatrogenic causes in both boys and girls include the late effects of childhood cancer treatment, total body irradiation prior to bone marrow transplantation, and iron overload in transfusion-dependent thalassaemia. In this paper, a brief description of the physiology of testicular and ovarian development is followed by a section on the causes and practical management of gonadal impairment in boys and girls. Protocols for pubertal induction and post-pubertal hormone replacement - intramuscular, oral and transdermal testosterone in boys; oral and transdermal oestrogen in girls - are then given. Finally, current and future strategies for assisted conception and fertility preservation are discussed.

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.

Right testicular volume is a dominant predictor of testicular function determined by sperm parameters and total testosterone

This study aims to evaluate the predictive value of left testicular volume (LTV) and right testicular volume (RTV) for testicular function respectively. Men who requested fertility testing for any reason were enrolled from December 2012 to November 2015. Subjects with primary scrotal diseases or a condition interfering reproductive system were excluded. Testicular volume (TV) was evaluated by scrotal ultrasound. Sex hormone and semen analysis including sperm concentration (SC) and sperm motility rate (SMR) were performed. Statistical analysis including comparison, stepwise linear regression and logistic regression was used. Two hundred and seventy-four patients with oligoasthenozoospermia/low testosterone and 27 control subjects were enrolled. Both LTV and RTV positively correlated with testicular function, and no differences were found between bilateral TV. RTV is the best independent factor associated with testicular function determined by SC (β=.292, p < .001), SMR (β=.227, p < .001) and total testosterone (TT) (β=.245, p < .001). Using a RTV value of 15.47 ml, the highest discriminating sensitivity and specificity were 66.7% and 62.4% respectively. RTV (<15 ml) was the only positive predictor for low testicular function (odds ratio=2.79, 95% confidence interval: 1.18-6.66; p =.020). RTV rather than LTV is the independent factor of overall testicular function determined by semen quality and TT levels. Further studies are needed to support and elucidate the difference in volume-function between bilateral testes.

The Dilemma of Adolescent Varicoceles: Do They Really Have to Be Repaired?

The primary indication for varicocele repair in adults, that of failed paternity, must be substituted in the adolescent population with surrogate parameters of testicular size differential and semen analysis. Making recommendations based on these two parameters is incredibly difficult because studies often have contradictory findings, different patient populations, and lack of long-term follow up of the key endpoint, paternity. Therefore, it is not a surprise that recommendations for adolescent varicocele repair are general (with some exceptions) and necessarily so because of limitations in quality of evidence. Apart from pain, all indications for varicocele repair in adolescence remain controversial. This highlights the most important task for future studies: to prevent pediatric urologists from allowing a potentially damaging process to go untreated, while at the same time avoiding unnecessary intervention on a highly prevalent condition.

The natural history of semen parameters in untreated asymptomatic adolescent varicocele patients: A retrospective cohort study

INTRODUCTION

Adolescent males with varicoceles present a dilemma for surveillance and treatment. Testicular volumetrics have not been shown to predict SA outcomes. Serial SAs are thus recommended in asymptomatic adolescent males with varicoceles and normal testicular development, but the natural history of semen parameters is unknown.

OBJECTIVE

To explore the natural history of semen parameters in adolescent boys with a left varicocele under active surveillance.

STUDY DESIGN

Adolescents with an asymptomatic unilateral left varicocele, Tanner V development, normal testicular volumes, and an initial SA were retrospectively reviewed in a single-institution prospectively followed cohort. Total motile count (TMC) was calculated. A cutoff of TMC Z 20 million was used to dichotomize SA results into "normal" or "poor." Those with poor SA were offered repeat SA. Cumulative probabilities of normal TMC over successive rounds of SA were calculated. Bivariate models were used to explore associations of a second consecutive poor TMC with age and varicocele grade.

RESULTS

A total of 216 patients provided an initial SA between 1992 and 2015. We excluded 17 for a history of cryptorchidism or incomplete SA data for a final cohort of 199 patients with median follow-up of 3.3 years (interquartile range 1.5-5.6 years). The mean age at initial SA was 17.9 years (range 14.8-21.8 years). One hundred and nine out of 199 had an initial normal TMC. Of the 90 out of 199 with an initially poor TMC, 51 had repeat SA and 24 of the 51 patients improved to normal TMC. Of the 27 patients with two consecutive poor TMCs, 15 had a third SA and five out of 15 improved to normal TMC. Thus, cumulatively, 55%, 67%, and 69% of all patients had a normal TMC after an initial, second, and third SA, respectively. However, fewer patients in each round of SA normalized their TMC (Figure). Neither age nor varicocele grade was associated with a second consecutive poor TMC.

DISCUSSION

Two-thirds of Tanner V boys with an uncorrected varicocele and normal testicular volumes achieve a normal TMC regardless of varicocele grade or age. Despite Tanner V development, 47% with an initial "poor" SA will improve to normal status without surgery. However, a small subgroup of patients will have persistently poor TMC and thus should be targeted in future research for timely intervention.

CONCLUSION

Semen parameters improve over time. SA should be followed and repeated at least once in symptomatic Tanner V boys with varicoceles.