Varicocele in schoolboys

"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.

Effect of physical activity level and occupation on resolution of pain after varicocelectomy: A prospective clinical study

INTRODUCTION AND OBJECTIVES

Persistent scrotal pain after varicocelectomy is stressful for both surgeon and patient. The number of researches focusing on which patient will benefit more from the operation is increasing in the literature. In this prospective study, we aimed to investigate whether the patient's physical activity levels and occupations affect the success of varicocelectomy in terms of pain relief.

MATERIALS AND METHODS

The data of 176 patients who underwent subinguinal microscopic varicocelectomy were analyzed according to BMI, age, varicocele grade, laterality, duration of pain, testicular volume difference, quality of pain, level of physical activity, and profession. The International Physical Activity Questionnaire was used to evaluate the level of physical activity. Patients were grouped as inactive, moderately active, and active according to this scale. Visual analog scale (VAS) scores of the patients were recorded before and after the procedure.

RESULTS

135 patients (76.7%) reported complete resolution of their pain. Partial resolution of pain was observed in 34 patients (19.3%). Seven patients (4%) complained of the same pain level. Univariate analysis showed that patient occupations and physical activity levels significantly affected the pain level (p=0.041, p=0.032, respectively). In the multivariate analysis, only physical activity levels of the patients were statistically significant in predicting the resolution of pain (p=0.024).

CONCLUSIONS

Patients with low physical activity levels who underwent microscopic varicocelectomy surgery are less likely to have postoperative pain.

Effect of somatometric parameters on the prevalence and severity of varicocele: a systematic review and meta-analysis

BACKGROUND

Published studies have shown contradictory results regarding the relationship between somatometric parameters and varicoceles. We performed a systematic review and meta-analysis to investigate the possible effects of age, height, weight, and body mass index (BMI) on the presence and severity of varicoceles.

METHODS

Databases including EMBASE, MEDLINE, PubMed, Cochrane Library, China National Knowledge Infrastructure (CNKI), Web of Science, and Google Scholar were systematically searched to identify relevant articles published up to March 2020. Two researchers independently identified eligible articles and extracted data. Cochran's Q statistic and I² statistics were used to assess heterogeneity. Meta-analysis was performed using StataSE 12.0 software (StataCorp LP, USA). Random-effects models were used to obtain the weighted mean differences (WMDs) and 95% confidence intervals (CIs). Publication bias was assessed using Begg's funnel plot and Egger's regression test.

RESULTS

The search strategy produced 272 articles, of which 18 articles were eligible according to the inclusion/exclusion criteria. A total of 56,325 patients with varicocele and 1,334,694 patients without varicocele were included in the meta-analysis to evaluate the effect of somatometric parameters on the presence and severity of varicocele. The overall results demonstrated that the presence of varicoceles was significantly associated with height (WMD = 1.41, 95% CI = 1.07 to 1.74, P < 0.001) and inversely correlated with BMI (WMD = - 1.35, 95% CI = -1.67 to - 1.03, P < 0.001) but not with age (WMD = -0.93, 95% CI = -2.19 to 0.33, P = 0.149) or weight (WMD = 0.24, 95% CI = -2.24 to 2.72, P = 0.850). The severity of varicocele was inversely correlated with increased BMI but not with age.

CONCLUSION

The presence of varicoceles was significantly associated with height and inversely correlated with BMI.

Is there a relationship between varicocele and testosterone levels?

OBJECTIVES

The goal of this work was to study the relationship between presence of varicocele and testosterone serum levels in adulthood.

METHODS

A comparative, cross-sectional study of 387 men who consulted for erectile dysfunction. Age, body mass index (BMI), diabetes (DM), and presence of varicocele were related to testosterone levels through uni- and multi-variate analysis.

RESULTS

A total of 248 cases (70.8%) had no varicocele, 46 (13.1%) had grade I varicocele, 36 (10.3%) grade II, and 20 (5.7%) grade III. The mean total testosterone levels were 4.77 ng/mL in the non-varicocele group and 4.34 ng/mL in the varicocele group (p = .91), while free testosterone levels were 69.81 and 73.24 pg/mL (p = .18), respectively. In the multivariate analysis, BMI> = 30 was related to low total testosterone levels (OR: 2.94, p < .001) and low free testosterone (OR: 2.01, p = .01), while advanced age associated with low levels of free testosterone (OR: 1.04, p < .001).

CONCLUSIONS

We were not able to establish a relationship between the presence of varicocele and decreased serum testosterone levels. Other factors already described, such as obesity and age, were related to low levels of total and free testosterone.

The prevalence and severity of varicocele in adult population over the age of forty years old: a cross-sectional study

Objectives: To investigate the prevalence and severity of varicocele in adult population over the age of 40. We also measured testicular size, consistency, and total testosterone levels with an aim to observe the effect of varicocele on testis as men age. Methods: Two hundred twenty-four patients with varicocele, 241 patients without varicocele who admitted to our clinic were enrolled in the study. We stratified participants by four age groups (40-49, 50-59, 60-69, >70 yr). Patients were grouped according to varicocele grade and laterality. The morning testosterone level was drawn. The subgroups were compared with each other. Results: Overall, varicocele prevalence was 48%. Of the patients, 104 had unilateral, 120 had bilateral varicocele. Of the patients with varicocele, 62 (13.30%) were found as grade 3, 99 (21.10%) were grade 2, and 63 (13.60%) were grade 1. The percentages of smaller testes in grade 1, grade 2, and grade 3 varicocele group were 20.60, 79.80, and 88.70 and a significant association was detected. Age stratification of the data revealed the smaller and soft testis prevalence as well as higher grade varicocele prevalance increased in older age groups. Conclusions: Varicocele presence is associated with lower testicular size, softer testicular consistency, and lower testosterone levels, especially in older patients with bilateral and high-grade varicocele.

Laparoscopic treatment of varicocele within adolescents in two African countries

Varicocele is often ignored by adolescents and their parents, in our context. The aim of the study is to present the indications and results of laparoscopic treatment in a population of adolescent students.

SUBJECTS AND METHODS

It is a descriptive and analytical prospective study over a period of 9 months (January to September 2013), focussed on cases of varicocele Grade 3 found in adolescents during a screening, and who underwent surgical treatment by laparoscopy. The laparoscopic treatment was done as part of a training mission to paediatrics surgeons, through a European Non-governmental organisation in two university hospitals in Africa. Of 2724 adolescent students examined, 149 (5.47%) had a varicocele. The average age was 16.39 ± 2.05 years (12 and 19). The side was unilateral (79.19%) with 76.51% left or bilateral (20.81%) (P = 0.00). According to the classification of Dubin and Amelar, there were 58 (38.92%) cases of Grade 1, 66 (44.30%) were Grade 2 and 25 (16.78%) were Grade 3.

RESULTS

The laparoscopic treatment was performed in 23 patients with varicocele Grade 3, by modified Palomo's technique, sectioning a segment of vessels between clips (15) between nodes (2) or after coagulation without clips and ligation (6). The hospital stay was 36 h. It has been observed one case of post-operative moderate vaginal hydrocele and 11 cases testicular hypertrophy.

CONCLUSION

The laparoscopic treatment of varicocele in adolescents reduces post-operative morbidity related to conventional open surgery. This technique has been available in two poor African countries through partnership north-south.

Indigo carmine dye-assisted lymphatic-sparing laparoscopic Palomo varicocelectomy in children

The ideal method for varicocelectomy in children remains controversial. We present our experience with dye-assisted lymphatic-sparing laparoscopic varicocelectomy (LSLV) in children, which overcomes the limitations of previously described techniques.

MATERIALS AND METHODS

Five consecutive LSLVs were performed over a period of three years on children with a mean age of twelve years. The varicocele grade was three in one case and grade 2 in four cases, respectively. A left subdartos injection of 2 ml of Indigo carmine dye was done using a 25-gauge needle at ten minutes before an operation. A scrotal injection of lymphatic dye was utilized to spare at least one lymphatic and the remaining spermatic vessels were divided.

RESULTS

Lymphatic-sparing was accomplished in all cases. No peri-operative complication was noted. We spared one lymphatic channel in one patient (20%) and two channels in four patients (80%). There were no cases of hydrocele or residual varicocele.

CONCLUSION

Dye-assisted LSLV is easily accomplished with an excellent surgical outcome and sparing one or two lymphatics appears to be sufficient to avoid secondary hydrocele.

[Epidemiological and clinical aspects of visible urogenital malformations among adolescent's schoolboys at Cotonou]

AIMS

To detect systematically visible urogenital malformations (VUGM) in adolescents and describe their epidemiological and clinical aspects.

PATIENTS AND METHODS

It was a cross sectional, descriptive and analytical study, conducted from February to August 2012. Upon 2724 adolescents from 10 to 19 years old, of the public secondary schools of Cotonou. Among the 26,594 registered pupils, 2724 were included and examined after a randomized sampling of 30 clusters.

RESULTS

The mean age of the pupils was of 15 ± 2.30 years (11-19 years), with a peak at 18 years. The prevalence of the VUGM was slightly higher (9.57%) in individuals those had parents with low socioeconomic level. The prevalence of the VUGM was high in Yoruba and related (P=0.02). It was stronger (9.84%) among subjects in puberty period's than in pre-puberty (6.69%) (P=0.03). From the 253 having VUGM, 78 (30.83%) had 146 functional signs. It was indexed 266 affections and of malformatives associations in 21 pupils (8.30%). Varicocele was the most frequent (5.47%), followed by inguinal hernia (0.99%), hydrocele (0.88%), anomalies of testis migration (0.59%), cyst of spermatic cord (0.51%), insulated testicular hypotrophy (0.48%), micro-penile (0.33%), hypospadias (0.22%), penile curvature (0.22%) and epididymis cyst (0.07%).

CONCLUSION

Among patients who had VUGM, the majority had at least a varicocele, which occupies so far the first place within these malformations at the adolescents in Cotonou.

Varicocele among healthy young men in Turkey; prevalence and relationship with body mass index

AIM

Varicocele is characterized by abnormal tortuosity and dilatation of the veins of the pampiniform plexus within the spermatic cord and is one of the causes related to male infertility. This study aimed to investigate the correlation between varicocele and somatometric parameters. We also aimed to determine prevalence and treatment ratio of this disorder among healthy young Turkish men.

MATERIALS AND METHODS

A total of 2061 young men aged from 19 to 34 years was enrolled and cross sectionally evaluated for status of varicocele. Body mass index was calculated. Patients were categorized as normal weight, overweight and obese using by National Institutes of Health criteria. Patients underwent physical examinations for the presence and grade of varicocele. If the varicocele was found and previously submitted to different treatment modalities, the age of treatment and outcomes were recorded.

RESULTS

Varicocele was present in 498 men (24.2%). The mean age of the participants was 22.7 ± 1.8 years, and the median BMI was 22.8 ± 2.0 kg/m². There were no significant differences in age, height, weight and BMI among the patients with different grades of varicocele (p > 0.05). Although no significant difference was found in varicocele prevalence between normal weight and over-weight participants (p > 0.05), obese participants had significantly lower varicocele prevalence compared with normal or over weight participants (p = 0.006). A total of 49 men had scrotal pain and the treatment ratio was only 2.8%.

CONCLUSION

Prevalence of varicocele was found in about 24% of healthy young Turkish population. Participants with varicocele had significantly lower BMI values compared with those without varicocele. Our findings supported the hypothesis that individuals with a greater BMI may have advantages in relieving the varicocele, but further studies are required to clarify this issue. Additionally treatment ratio was low among young men with varicocele.

Predictors of pain resolution after varicocelectomy for painful varicocele

Varicocelectomy is a management option for patients with painful varicocele. In this study, we assessed the effectiveness of varicocelectomy for painful varicocele and examined the factors that might be predictive of outcome. All patients who underwent a varicocelectomy for pain between February 2007 and July 2009 were included. A review of patient medical records was conducted; patient age, body mass index (BMI), grade, location of the varicocele, testicular volume, duration and quality of the pain (dull, dragging, throbbing or sharp) and surgical technique (inguinal versus subinguinal) were documented. All parameters were compared with the resolution of pain (complete, partial or failure). We followed up on 53 of 104 patients (51.0%). Complete postoperative resolution of pain was reported by 28 patients (52.8%), whereas 22 (41.5%) reported partial resolution. Only three patients (5.7%) reported failure. No relationship was observed between postoperative pain resolution and age, BMI, grade of varicocele, location of varicocele, ipsilateral testicular hypotrophy, quality of pain or surgical technique. The duration of pain before surgery was the only factor that correlated with postoperative pain resolution (univariate, P=0.004; multivariate, P=0.002). Our results indicate that varicocelectomy is an effective treatment for painful varicocele in properly selected patients, and that duration of pain before surgery may be predictive of outcome.

Lymphatic sparing laparoscopic Palomo varicocelectomy for varicoceles in children: intermediate results

OBJECTIVES

Varicocele is a relatively rare disorder in children that can lead to testicular atrophy and infertility. The ideal surgical treatment for varicoceles is still a matter of controversy because of the frequency of postoperative complications. Here, we report our series of children who underwent lymphatic sparing laparoscopic Palomo varicocelectomy.

PATIENTS AND METHODS

A total of 46 boys, 9 to 14 years old, underwent laparoscopic repair for varicoceles between January 2002 and December 2007. All of them had a left-sided varicocele. The varicocele was diagnosed by physical examination and Doppler ultrasonography. The laparoscopic procedure included obligatory dissection and preservation of the lymphatic vessels, followed by double ligation of the spermatic vessels. Follow-up for these children included physical examination and Doppler ultrasonography.

RESULTS

Lymphatic sparing laparoscopic Palomo varicocelectomy was feasible in all 46 (100%) of the children. Mean operative time was 34.2 minutes (range, 25-42 minutes). There were no intraoperative complications. One patient recurred because of incomplete ligation of spermatic vein. Mean follow-up was 20 months (range, 7-32 months). Hydrocele formation, testicular atrophy, and testicular hypertrophy were not observed postoperatively. However, 2 preoperative hypotrophic testes were noted with 10.4% and 12.5% decreases in size.

CONCLUSIONS

Our study reveals that lymphatic sparing laparoscopic Palomo varicocelectomy in children is safe, effective, and the reliable treatment of pediatric varicocele. However, long-term follow-up is required to best characterize ultimate outcome.

Adolescent varicocele: who is at risk?

OBJECTIVES

Varicocele results from the abnormal dilation of the veins of the pampiniform plexus and is the most common identifiable cause of male infertility. It can develop during puberty and thus affect the testicular growth and function. The aim of this study was to determine the prevalence and the risk factors for the development of the varicocele among Bulgarian boys.

METHODS

In a prospective study, 6200 boys from 5 regions of the country aged 0 to 19 years were evaluated for varicocele. All were clinically healthy. Height, weight, testicular volumes, penile length, and penile circumference were also examined.

RESULTS

Varicocele was found in 4.1% of all investigated boys, whereas in the age group 10 to 19 years, it was 7.9%. After adjustment for age, the negative factors associated with the development of the disorder were height, penile length, and penile circumference, whereas the weight and BMI had a protective role. The prevalence of varicocele demonstrated clear regional differences, and it was found significantly more often among dark-eyed boys. The incidence of the disease increased rapidly during midpuberty.

CONCLUSIONS

The incidence of varicocele is related to some somatometric parameters and with the accelerated pubertal development. Longitudinal studies are needed to clarify better the relations between the adolescent varicocele and puberty.

Cardiovascular evaluation of young patients with varicocele

OBJECTIVE

To evaluate cardiovascular risk factors and demographic parameters in patients with varicocele.

DESIGN

Although some pathophysiologic hypotheses have been suggested to explain the etiology of varicocele, the exact mechanism underlying varicocele is not yet known. The coexistence of arterial and venous system pathologic conditions has been reported recently, including varicosities of the coronary venous system and leg veins. Cardiovascular risk factors have not been evaluated previously in patients with varicocele. In addition to the presence of cardiovascular risk factors and demographic parameters, we assessed the prevalence of peripheral varicose veins in patients with and without varicocele.

PATIENT(S)

Study groups consisted of 52 patients with varicocele and 100 patients without varicocele younger than 50 years old.

RESULT(S)

There were no statistically significant differences between the two groups with respect to presence of hypertension, diabetes mellitus, hyperlipidemia, family history of coronary artery disease, body mass index, age, and height. The weight and presence of peripheral varicose veins in the patients with varicocele were significantly higher than in those without varicocele. It was found that presence of peripheral varicose veins was independently and positively associated with varicocele.

CONCLUSION(S)

We have demonstrated that varicocele is not associated with cardiovascular risk factors or demographic parameters. However, the presence of peripheral varicose veins is positively associated with varicocele, suggesting a possible common pathologic step.

Body size and weight as predisposing factors in varicocele

OBJECTIVE

The literature regarding the constitutional type of children and adolescents with varicocele is inconsistent. The aim of this investigation was to examine a possible influence of weight, height and body mass index (BMI) on the formation of varicoceles during childhood and adolescence.

MATERIAL AND METHODS

In a retrospective data analysis, 193 Caucasian children and adolescents aged 9-19 years (mean age 14.7 years) with left-sided varicocele grade 2-3 were studied. The weight, height and BMI of the subjects were compared with the age-correlated normal values currently accepted in Germany. Additionally, the familial disposition for varicocele and the occurrence of relevant concurrent diseases were considered.

RESULTS

In the group of patients examined, the mean percentiles of weight (57th) and height (58th) were significantly above and the mean BMI percentile (42th) was significantly below the age-correlated 50th percentile for the normal population (p=0.019, 0.005 and 0.002). In our case material, 12.2% of all brothers of the patients had varicoceles.

CONCLUSIONS

The results of this investigation suggest a correlation between physical appearance and the formation of a varicocele during childhood or adolescence. We were able to demonstrate that patients with varicocele were heavier and taller than an age-correlated normal population, but had a distinctly lower BMI. Further studies are needed to verify whether this rather athletic habitus, together with the postulated difference in muscle:fat ratio, represents an important etiologic factor for varicocele formation.

Is the laparoscopic Palomo procedure for pediatric varicocele safe and effective?

BACKGROUND

Varicocele is a rare disorder in children that can lead to testicular atrophy and infertility; therefore, radical treatment is frequently required. Whatever treatment is chosen, postoperative complications are fairly common (hydrocele, recurrence, persistence, and testicular atrophy). Laparoscopic varicocelectomy (the laparoscopic Palomo procedure) is one of the surgical options that has recently gained popularity. The aim of this study is to assess the safety and effectiveness of laparoscopic Palomo varicocelectomy by describing a series of patients operated on during a 9 year period at the Royal Hospital for Sick Children in Edinburgh.

METHODS

This is a retrospective unicentric study including patients operated on between June 1995 and June 2004. All patients preoperatively underwent ultrasound scan of the testicles (color Doppler) and the abdomen. Indications for surgery included symptoms, high-grade varicocele (grade II and III), and testicular atrophy. Pneumoperitoneum was created using carbon dioxide insufflation with intraabdominal pressure up to 12 mmHg. Three 5 mm ports were inserted. The first port was inserted just below the umbilicus (telescope) under direct vision, and the others were inserted at the left flank and in the suprapubic region. All the enlarged spermatic and vas vessels were ligated or clipped. Outcomes and possible intraoperative, postoperative, or long-term complications are described.

RESULTS

Forty-one patients were included in the study. Ninety percent of symptomatic patients improved significantly postoperatively, and 62% of patients with preoperative testicular atrophy showed postoperative catch-up growth of the involved testis. Nevertheless, hydrocele represents the most frequent postoperative complication in this series of patients. Approximately 15% of the patients required some sort of further surgical intervention (12% because of postoperative hydrocele occurrence).

CONCLUSIONS

The laparoscopic Palomo procedure is a safe and effective surgical option for the treatment of pediatric varicocele, although it carries a fairly high risk of postoperative hydrocele. Postoperative hydrocele seems to be related to some sort of lymphatic obstruction, therefore lymphatic sparing procedures that can be accomplished laparoscopically should be reconsidered. Nevertheless, their feasibility and effectiveness need to be more carefully assessed.