The adolescent varicocele: the crucial role of hormonal tests in selecting patients with testicular dysfunction

Varicocelectomy in adolescents - Does it safeguard future fertility? A single centre experience

BACKGROUND

There is paucity of literature comparing varicocelectomy to observant management amongst adolescent boys with hormonal and semen abnormalities resulting from high grade unilateral varicoceles and consequent testicular volume loss. Furthermore, it is not known whether surgical correction in such adolescents improves paternity rates in future compared to their non-operated cohort.

OBJECTIVE

The primary objective was to compare adolescent boys with unilateral high grade varicocele with associated ipsilateral testicular volume loss who were operated versus those who were not, in relation to their fertility markers (hormonal, semen parameters, and testicular volume) over a 5 year follow up period. The secondary objective was to compare the paternity rates in the respective groups over long term.

STUDY DESIGN

This was a single center, retrospective study of a prospectively maintained database conducted from 2010 to 2020, based on a standardized protocol. All adolescent boys >15 years of age (middle and late adolescence), with grade II or III unilateral varicoceles with abnormal fertility markers, who were operated (Group A) and not operated (Group B) were included. The changes in hormonal assay, sonographic assessment, semen analysis at presentation, 1st year and the 5th year follow up amongst both the groups were collated and analysed. Primary paternity rates amongst both the groups was documented by telephonic or email conversations.

RESULTS

Of the 182 boys referred for varicocele management, 110 boys (Group A -70 boys and Group B - 40 boys) satisfied our inclusion criteria and were analysed. Mean age at presentation amongst Group A boys was 16.5 years (15-18 years) and Group B boys was 16 years (15-18 years). Grade III varicoceles were more predominant amongst both the groups. There was a significant improvement in all Group A boys (operated) in the fertility markers from the time at presentation to the 5th year follow up (p < 0.001). In Group B, (boys not operated) there was no significant improvement in the above parameters. The testicular catch up growth was 92% at the 5th year follow-up in Group A and 42% in Group B. At long term follow-up, the paternity rate was 80% and 36% in Group A and B respectively.

DISCUSSION AND CONCLUSION

In adolescent boys in whom hormonal assay, testicular volumes and semen characteristics are negatively affected by high grade unilateral varicoceles, surgical correction could normalize these values, thereby safeguarding their fertility in the long term.

Management of adolescent varicocele

Varicocele is defined as an abnormal dilation and tortuosity of the internal spermatic veins found within the pampiniform plexus. It is a common finding in adolescents and adult men alike, however its diagnosis in the adolescent population poses different dilemmas in regard to indications for treatment than in adults. Failed Paternity is a clear-cut indication for repair in adult men attempting to father children. In adolescents, the physicians, family and patients must consider potential for future fertility problems which may or may not actually become of concern. Assessing the degree of negative effect of the varicocele on an adolescent's testicular health can also be difficult as teenagers typically are not asked to provide semen for analysis and thus surrogate markers for testicular health such as testicular size differentials must be used. Treatment options for the adolescent varicocele are similar to options in adult populations. While risks and benefits of various techniques can be considered, the gold standard for varicocele repair in adolescents has not been clearly defined. We aim to discuss diagnosis of varicocele, considerations for initiating treatment of varicocele in the adolescent, and techniques for management.

Hormonal evaluation in adolescents with varicocele

INTRODUCTION

Varicocele is one of the most frequent disease affecting the fertility potential; OBJECTIVE: the aim of this study is to assess the correlation between clinical and radiological grade of varicocele and hormonal values.

STUDY DESIGN

The data about adolescents with left unilateral varicocele aged between 13 and 16 years, with Tanner stage V, followed at the Authors' Institution between September 2016 and September 2019 were investigated; inclusion and exclusion criteria were created. Patients underwent standard visit, Ultrasound, Doppler velocimetry and hormonal tests (at T0 and T1). Those patients with testicular hypotrophy underwent surgery.

RESULTS

During the study period, 75 subjects with left unilateral varicocele were enrolled; 8 patients were excluded.A total of 67 patients were then studied. Among these patients, 37 had testicular hypotrophy, while the others had normal testicular volume. There was no correlation between grade of varicocele and testicular hypotrophy (p = 0.12); among those patients with testicular hypotrophy, there was a statistical correlation with the grade of spermatic vein reflux (grade 4 vs grades 1-2-3) (p = 0.03). Focusing on hormonal values, there was a statistical significant difference between FSH levels, clinical grades of varicocele and grade of spermatic vein reflux: FSH levels were higher in patients with clinical grade 3 varicocele respect to patients with grade 1-2 varicocele and, in particular, patients with grade 3 varicocele, testicular hypotrophy and grade 4 spermatic vein reflux (14 patients) had higher FSH level respect to others (p = 0.02). After surgery there was a significant FSH reduction.

CONCLUSIONS

Our results demonstrate that higher grade of spermatic vein reflux is associated with testicular hypotrophy and higher FSH levels.

Effects of Morinda officinalis Polysaccharide on Experimental Varicocele Rats

Morinda officinalis is a traditional Chinese herbal medicine, which has been used to tonify the kidney and strengthen yang for a long time in China. In this study, the effects of M. officinalis Polysaccharide (MOP) on experimental varicocele adolescent rats were investigated. The result showed that varicocele destroyed the structure of the seminiferous epithelium and decreased the TJ protein expression (Occludin, Claudin-11, and ZO-1), testosterone (T) concentration in the left testicular tissue and serum, and serum levels of inhibin B (INHB), while increasing the levels of cytokines (TGF-β3 and TNF-α) in the left testicular tissue, as well as serum levels of gonadotropin-releasing hormone (GnRH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and antisperm antibody (AsAb). MOP repaired the damaged seminiferous epithelium and TJ and reduced the levels of cytokines (TGF-β3 and TNF-α) as well as serum levels of GnRH, FSH, LH, and AsAb, while upregulating TJ protein expression, T level in the left testicular tissue and serum, and serum INHB levels. In summary, we conclude that MOP promotes spermatogenesis and counteracts the varicocele-induced damage to the seminiferous epithelium and TJ, probably via decreasing cytokines (TGF-β3 and TNF-α) levels and regulating the abnormal sex hormones levels in experimental varicocele rats.

Varicocele and testicular function

Testicular varicocele, a dilation of the veins of the pampiniform plexus thought to increase testicular temperature via venous congestion, is commonly associated with male infertility. Significant study has clarified the negative impact of varicocele on semen parameters and more recent work has shed light on its detrimental effects on the molecular and ultrastructural features of sperm and the testicular microenvironment, as well as more clearly defined the positive impacts of treatment on couples’ fertility. The relationship between varicocele and testicular endocrine function, while known for some time based on histologic evaluation, has become more apparent in the clinical setting with a growing link between varicocele and hypogonadism. Finally, in the pediatric setting, while future study will clarify the impact of varicocele on fertility and testicular function, recent work supports a parallel effect of varicocele in adolescents and adults, suggesting a re-evaluation of current treatment approaches in light of the progressive nature of the condition and potential increased risk of future disease.

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.

Evaluation and Management of the Adolescent Varicocele

PURPOSE

Varicocele is one of the most common genital conditions referred to pediatric urologists. Most adolescents with varicocele are asymptomatic and their fertility future (and surgery benefit) is largely unknown. This review assesses varicocele evaluation, management and indications for repair, as well as types and success of varicocelectomy.

MATERIALS AND METHODS

A systematic literature review was performed on Embase™, PubMed® and Google Scholar™ for adolescent varicocele. Original research articles and relevant reviews were examined, and a synopsis of these data was generated for a comprehensive review of clinical adolescent varicocele management.

RESULTS

The prevalence of adolescent varicocele is similar to the adult population. While ultrasound is the most sensitive method for determining testicular volumes, orchidometer measurement may be adequate to gauge significant discordance. Significant hypotrophy of the affected testis with poor total testicular volume may indicate a testis at risk and warrant surgical repair. Similar findings have been noted with an associated high peak retrograde venous flow. Testicular hypotrophy often resolves following surgery but may also improve spontaneously if followed through adolescence. Continued scrotal pain despite adequate support or serial abnormal semen analysis in Tanner stage V boys is an indication for varicocelectomy. Artery and lymphatic sparing techniques (microscopic subinguinal or laparoscopic) are associated with the lowest risk of recurrence and complications.

CONCLUSIONS

Overtreatment and under treatment are medically and financially costly. Abnormal serial semen analysis with or without testicular hypotrophy is an indication for varicocele repair. If observation remains the treatment, followup with an adult urologist should be encouraged until paternity is achieved.

Impact of varicocele on biological markers of gonadal function

PURPOSE

The aim of this study is to evaluate the potential effect of varicocele in the hormonal and clinical profile of adolescents.

METHODS

Twenty adolescents at Tanner stage 4-5 with left varicocele were studied and compared with a control group of 20 healthy adolescents. All patients underwent ultrasonographic testicular volumetry as well as hormonal evaluation of inhibin B, testosterone, baseline and gonadotropin-releasing hormone stimulated, follicle-stimulating hormone as well as luteinizing hormone. Statistical analysis was performed using the student's t test with p value <0.05 taken as statistical significant.

RESULTS

Patients with varicocele showed reduced levels of inhibin B compared to controls and a significant reduction in the testicular volume on the affected side. The response of luteinizing hormone to gonadotropin-releasing hormone stimulation was significantly higher in the varicocele group compared to the control group. Furthermore a significant inverse relationship of inhibin B compared to follicle-stimulating hormone was noted.

CONCLUSION

Serum inhibin B levels could represent a useful marker of Sertoli cell damage caused by varicocele.

Influence of open testicular biopsy in prepubertal rats on rats' adulthood fertility with correlation to serum levels of inhibin B and follicle stimulating hormone

OBJECTIVE

Open testicular biopsy (OTB) is one of the options to accurately assess fertility potential of the undescended testis. The aim of the study was to investigate consequences of OTB in prepubertal rats on their adulthood fertility.

METHODS

Thirty-eight prepubertal male rats were divided into three groups depending on day 20 procedure. The first group was the control group, the second sham operated and the third has left OTB. Bilateral orchiectomy was performed on day 70 to all groups, with determination of serum inhibin B and follicle stimulating hormone (FSH). Removed testes were compared according to the weight, volume, spermatogenesis, histological and apoptotic changes in both testes with differences in serum levels of inhibin B and FSH.

RESULTS

Ipsilateral testicular weight, volume, and spermatogenesis reduction with a reduction of tubular number, diameter and germinative epithelium was found in OTB group. Significant increase in apoptotic index was found in biopsied testis without compensatory hypertrophy of contralateral testis. Differences of inhibin B and FSH were not statistically significant among three groups.

CONCLUSION

OTB in prepubertal rats has detrimental effects on fertility in adulthood. It does not cause compensatory hypertrophy of the contralateral testis nor does it disturb serum levels of inhibin B and FSH.

[Variocele in adolescents]

Up to 20% of adolescents have a varicocele. Often a varicocele is an incidental finding during a physical examination. However, adolescents with a varicocele might suffer from pain or they may have noticed a difference in the volume of the testes. The diagnostic investigation of the ejaculate in adolescents is difficult because no age-dependent spermiogram standard values exist. Endocrinological tests are also difficult because of the physiological variability of testosterone and gonadotropins during adolescence. The difference in testes volume normalizes in half of the boys without any therapy during maturation. Most adolescents with a varicocele have a normal semen analysis. The sperm parameters are the most important factor for treatment decision making.If sperm concentration, motility, and morphology are normal, active surveillance with regular control examinations are recommended even if the volume of the testis is divergent. Pathologic sperm parameters should lead to an operative treatment. The microsurgical subinguinal technique is the method of choice due to the low complication and reoperation rates. The sperm concentration, morphology, and motility increase postoperatively as well as the volume of the testis. It is not clear whether the improved sperm parameters lead to improved spontaneous pregnancy rates later in life. Whether scrotal pain decreases after operative therapy is uncertain because of the subjectivity of pain.Until now there are only a few studies with small and very heterogeneous case numbers so that no clear recommendation for the treatment of a varicocele in adolescents can be made. The difficulty in the treatment decision-making is preventing reduced fertility, while avoiding overtreatment.

Active surveillance of the adolescent with varicocele: predicting semen outcomes from ultrasound

PURPOSE

We hypothesized that active surveillance of the adolescent varicocele is not associated with a high prevalence of suboptimal semen analysis and that patients with abnormal semen analysis have smaller testicular volumes and larger volume differentials.

MATERIALS AND METHODS

We conducted an institutional review board approved retrospective cohort study of adolescents with a clinically detected varicocele. Patients were initially observed by serial scrotal ultrasound evaluating testicular size and differential. Semen analysis was routinely collected in Tanner V cases, around age 18 years. Prevalence of normal semen analysis parameters was calculated, and logistic regression was used to model the ability of age at presentation and testicular volume parameters to predict a normal semen analysis.

RESULTS

A cohort of 73 patients underwent surveillance with a mean ± SD age at presentation of 15.5 ± 2.3 years. Median followup was 2.7 years, during which time subjects underwent a median of 3 scrotal ultrasounds. A low total motile count was found in 48 patients (66%). Neither age at presentation nor testicular volume differential could predict normal semen volume, density, sperm motility or total motile count. Total testicular volume from the final ultrasound predicted total motile count (p = 0.008). However, the collective observations of volume during the entire period of surveillance could not predict total motile count (p = 0.847).

CONCLUSIONS

There is a high prevalence of suboptimal semen analysis in adolescents with a varicocele who are followed with active surveillance. Total testicular volume can predict total motile count at the end of adolescence but not throughout.

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.

[Varicocele in adolescents]

Testicular varicocele is present in 15 % of adolescent boys. The very impact of this pathology and who will be at risk of developing into infertility remains unclear. Research on the pathophysiology, results of surgical or radiological interventions and potential predictors for long-term impairment of spermatogenesis and thus fertility is still ongoing. Indications for treatment are mainly based on differences in testicular volumes as semen parameters are most often not available; however, whether testicular volume is a valuable prognostic parameter for later fertility remains questionable. Approximately 50 % of adolescent patients with varicocele experience spontaneous increase of testicular volume without any intervention.

The hemodynamic approach to evaluating adolescent varicocele

During adolescence, the risk of developing a varicocele increases. Prevalence is less than 1% in boys aged younger than 10 years, but approaches that of the general adult population (about 15%) during puberty. For adolescent males with varicoceles, surgical risk factors have not yet been clearly delineated and clinical severity correlates poorly with prognosis. Fortunately, the widespread use of Doppler ultrasonography is transforming the diagnostic work-up for this demographic. A continuous reflux detected by color Doppler ultrasound (CDUS) is thought to have a negative prognostic value and evidence suggests that a peak retrograde flow above 38 cm per second is a powerful predictor of lack of spontaneous improvement in adolescent patients with ≥ 20% asymmetry between testes. CDUS also enables the detection of varicocele resulting from reflux in the deferential vein adjunctive to a refluxing internal spermatic vein; a causality that accounts for approximately 15% of cases. In addition to a diagnostic role, hemodynamic parameters can be used to predict the risk of persistence or worsening asymmetry. Although further studies are necessary to validate single parameters, it seems that the more severe the reflux, the greater the likelihood that the patient will develop testicular asymmetry.

Treatment strategy for the adolescent varicocele

A varicocele is a dilatation of the testicular vein and the pampiniform venous plexus within the spermatic cord. Although rare in pediatric populations, the prevalence of varicoceles markedly increases with pubertal development. Varicoceles are progressive lesions that may hinder testicular growth and function over time and are the most common and correctable cause of male infertility. Approximately 40% of men with primary infertility have a varicocele, and more than half of them experience improvements in semen parameters after varicocelectomy. The decision to treat adolescents with varicocele is a controversial one. The task for pediatricians and urologists is to identify those adolescents who are at greatest risk for infertility in adulthood, in an effort to offer early surgical intervention to those most likely to benefit.

Expression of the Fas-ligand gene in ejaculated sperm from adolescents with and without varicocele

PURPOSE

To assess FasL mRNA levels in ejaculated sperm from adolescent patients with and without varicocele.

METHODS

Semen was obtained by masturbation following 2-4 days of ejaculatory abstinence, from 14 adolescents with varicocele grades II and III (study group), and 20 adolescents without varicocele (control group). Seminal analysis was done according to World Health Organization guidelines and morphology using Kruger's strict criteria. The Fas-ligand (FasL) gene expression was performed using reverse transcription and real-time quantitative polymerase chain reaction (RQ-PCR) analysis, according to the expression level of the housekeeping cyclophilin A gene. A Student's t-test was applied to compare the groups, and Spearman's rank test in order to verify possible correlations (p < 0.05).

RESULTS

Quantitative RQ-PCR demonstrated that the expression of FasL mRNA in sperm from the varicocele group was higher than in the control group. Also, sperm concentration was higher in the controls, when compared to the varicocele group. When submitted to correlation analysis, adolescents with varicocele presented a correlation between sperm concentration and FasL gene expression levels (r = -0.470), not observed in controls.

CONCLUSION

Our results allow us to conclude that, in adolescents with varicocele presenting lower sperm concentration, FasL mRNA levels are higher than in adolescents without varicocele.

Varicocele and infertility: why a prevention?

The varicocele is the abnormal dilation of the veins of the pampiniform plexus, resulting from an altered venous drainage, and it is considered one of the main causes of male infertility. In this paper we review the most recent observations on the histological, endocrinological, biochemical and clinical alterations reported in adolescents with left idiopathic varicocele. Data indicate that varicocele progressively impairs the reproductive function of the testis. Treatment could improve a number of such damages.

Relationship of varicocele grade and testicular hypotrophy to semen parameters in adolescents

PURPOSE

Surgical indications for correcting adolescent varicocele include high varicocele grade and testicular hypotrophy. To our knowledge these findings have not been correlated with semen parameters to date. We examined the relationship between unilateral left varicocele grade or the testicular volume differential and semen parameters in adolescents.

MATERIALS AND METHODS

Semen analyses were done in 57 Tanner stage V adolescent males at ages 14 to 20 years (mean+/-SD 18 +/- 1.6). Varicocele grade was determined by the attending urologist. Testicular volumes were determined by scrotal ultrasound performed by an attending sonologist. Data analysis was performed using nonparametric statistical methods.

RESULTS

Boys with testicular volume differentials greater than 10% vs those with differentials less than 10% had significantly lower sperm concentration and total motile sperm counts. For differentials greater than 20% these decreases were more dramatic. Percent motile sperm was significantly lower for boys with volume differentials greater than 20% vs those in the less than 10% and 10% to 20% categories. No significant differences were detected in percent normal morphology among the volume differentials. No significant differences were detected for any semen analysis parameter as a function of varicocele grade.

CONCLUSIONS

Sonographically derived volume differentials greater than 10% between normal and affected testes correlate with a significantly decreased sperm concentration and total motile sperm count. This finding may serve as a marker to identify adolescents with unilateral left varicocele who are at greatest risk for future infertility. At least semen analysis and close annual followup of these adolescents seem warranted.

Altered serum inhibin b levels in adolescents with varicocele

BACKGROUND/PURPOSE

Different studies have evaluated testicular hormonal dysfunction in adolescent varicocele but with variable results. Recently, inhibin B has been proposed as a marker for spermatogenesis and Sertoli cell function. The aim of the present study was to study in a homogeneous cohort of adolescents inhibin B and other hormones to detect whether untreated varicocele may be associated with any modifications of these factors.

METHODS

Sixteen adolescents (mean age, 14.5 +/- 1.0 years), at Tanner stages 4 to 5 with grade II or III left-sided varicocele, underwent hormonal evaluation of inhibin B, basal testosterone, and both baseline and GnRH stimulated FSH and LH levels. Thirteen unaffected adolescents of age-matched and pubertal development were used as controls.

RESULTS

Patients with varicocele showed a significant reduction in the testicular volume of the affected side (13.3 +/- 4.1 vs 15.8 +/- 4.8 mL; P = .002) and significant reduced levels of inhibin B compared with controls (271.9 +/- 70.2 vs 327.1 +/- 34.9 pg/mL; P = .042). Inhibin B levels were significantly correlated with testes volume (r = 0.62; P = .0097). Other hormonal parameters were similar in both varicocele and control groups.

CONCLUSION

Inhibin B is reduced in adolescents with untreated varicocele, and it is positively correlated with testicular volume. This could be an early marker for Sertoli cell damage, with possible implications for spermatogenesis and could represent a new indication for varicocele repair.

Baseline follicle-stimulating hormone is a strong predictor for the outcome of the gonadotrophin-releasing hormone test in young men with unilateral medium- or high-grade varicocele

OBJECTIVE

To investigate whether the gonadotrophin-releasing hormone (GnRH) test is an adequate diagnostic tool to identify testicular dysfunction in men with strictly unilateral varicocele and defined testicular volume; and to identify any peripheral venous variable which would predict the result of the GnRH test.

PATIENTS AND METHODS

In all, 102 GnRH tests were done in men with a left-sided varicocele. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels were determined. After intravenous administration of 100 microg GnRH, stimulated LH and FSH levels were measured. FSH levels of >8.2 U/L and LH levels of >51.7 U/L were considered exaggerated.

RESULTS

In all, 50 men had an exaggerated GnRH test result; all had an exaggerated FSH response and six also had an elevated LH response. The baseline FSH levels were higher (P < 0.001) and the testicular volume was smaller (P < 0.01) in men with an exaggerated GnRH test response. All men with a baseline FSH level of >5.6 U/L had an exaggerated GnRH test response.

CONCLUSION

A baseline FSH level of >5.6 U/L is a good predictor of the GnRH test outcome. Leydig cell function seems mainly undisturbed.

Genitourinary issues in the male college student: a case-based approach

Five percent of all ambulatory visits by men 18 years of age or older include genitourinary symptoms as a reason for the visit. In this article, using typical, unusual, or otherwise instructive cases, the authors review a select group of genitourinary issues in the college-age male. Warts (human papilloma virus), is the most common sexually transmitted infection, and it may mimic other disease. Testicular cancer is one of the most serious diseases to confront health care providers. Varicoceles are the most common scrotal mass. Urethritis is a common presentation of sexually transmitted infection in the young adult male. Acute prostatitis is an unusual condition in the young adult, but it is easily treatable. Sexual dysfunction causes great distress in the young adult, but a systematic approach usually leads to a treatable psychological or environmental cause. With understanding of these medical conditions, the practitioner should feel comfortable addressing the most challenging genitourinary health needs of this population.

Controversies in male adolescent health: varicocele, circumcision, and testicular self-examination

PURPOSE OF REVIEW

The authors review three common clinical controversies encountered by primary care providers of adolescent males: management of varicoceles, the role of circumcision in the acquisition and transmission of sexually transmitted infections, and the value of teaching testicular self-examination.

RECENT FINDINGS

Recent findings in adolescent varicoceles have advanced knowledge regarding the cause of varicoceles, the mechanism by which they may lead to infertility, new screening methods, and optimal surgical management. Accumulating evidence shows circumcision to be protective against acquisition and transmission of sexually transmitted infections, and preliminary work also indicates the potential for protection against the spread of AIDS in Africa. Testicular self-examination remains an unproven screening modality that is suboptimally performed by at-risk patients.

SUMMARY

This review updates the provider on these topics and clarifies issues involved in these controversies