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INVITED COMMENTARY
Year : 2016  |  Volume : 18  |  Issue : 2  |  Page : 311

Asymptomatic postpubertal male with palpable left varicocele and subclinical right varicocele


Department of Infertility and Sexual Medicine, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510630, China

Date of Web Publication11-Dec-2015

Correspondence Address:
Dr. Yan Zhang
Department of Infertility and Sexual Medicine, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510630
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1008-682X.169992

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How to cite this article:
Zhang Y. Asymptomatic postpubertal male with palpable left varicocele and subclinical right varicocele. Asian J Androl 2016;18:311

How to cite this URL:
Zhang Y. Asymptomatic postpubertal male with palpable left varicocele and subclinical right varicocele. Asian J Androl [serial online] 2016 [cited 2020 May 26];18:311. Available from: http://www.ajandrology.com/text.asp?2016/18/2/311/169992 - DOI: 10.4103/1008-682X.169992

With the widespread use of scrotal ultrasonography, more and more subclinical right varicoceles have been detected in postpubertal males with palpable left-sided varicocele. [1] A significant relationship between testicular growth arrest and adolescent varicocele grades has been documented, [2] thus indicating that a decrease in semen quality might occur later in life. [3]

On the other hand, the benefits of surgical treatment in all adolescents with varicocele remain equivocal. [4],[5] Besides symptomatic adolescent varicocele, ipsilateral testis growth arrest is an acceptable treatment indication. Traditionally, testicular growth arrest will be confirmed when ipsilateral testis is 20% smaller compared to the other side. In such cases, a treatment is recommended. [6] However, there is no consensus on the definition of significant testicular hypotrophy. A range from 10% to 20% is described by different authors as a significant testicular size discrepancy. [7],[8]

There is still controversy about the value to repair isolated subclinical varicocele in infertile adults, [9] and the meaning of repairing subclinical varicocele at pediatric age is even more debatable. In adolescents with palpable left varicocele and subclinical right varicocele, when there is obvious testicular asymmetry, we recommend bilateral varicocelectomy based on the following reasons:

(1) There is evidence suggesting that simultaneous repair of left clinical and right subclinical varicocele is beneficial in adults [10],[11] though contrary opinion exists. [12] (2) A significant proportion of subclinical adolescent varicocele may progress to clinical varicocele rather than spontaneous resolution. [13] Moreover, sports may be associated with the progression of subclinical varicocele. [14]

In the presence of left clinical and right subclinical varicocele but no testicular asymmetry, the benefit of surgical intervention is unknown due to the lack of definition of normal testicular size in adolescents. It should be noted, however, that Chen et al. reported possible hypoplasia of right testicle in the presence of left varicocele and, therefore, comparison of bilateral testicle sizes may potentially miss some patients with testicular hypoplasia who may benefit from surgical intervention. [15] We incline to recommend surgical intervention to adolescents who present with the aforementioned given scenario. This is based on the fact that size comparison between testicles in the same individual may not be representative. [16] Nevertheless, the potential benefits and risks of surgery should be discussed in detail with the parents and the patient. In selected adolescents with varicoceles, semen analysis may be useful in decision-making [17] though the normal range for adolescent semen parameters is lacking. Hormonal tests may be potentially useful for evaluation of testicular function in adolescents with varicocele and helpful in selecting patients for treatment. [18]

 
  References Top

1.
Woldu S, Nees S, Van Batavia J, Spencer B, Glassberg K. Physical exam and ultrasound characteristics of right varicoceles in adolescents with left varicoceles. Andrology 2013; 1: 936-42.  Back to cited text no. 1
    
2.
Zampieri N, Zuin V, Corroppolo M, Ottolenghi A, Camoglio FS. Relationship between varicocele grade, vein reflux and testicular growth arrest. Pediatr Surg Int 2008; 24: 727-30.  Back to cited text no. 2
    
3.
Mori MM, Bertolla RP, Fraietta R, Ortiz V, Cedenho AP. Does varicocele grade determine extent of alteration to spermatogenesis in adolescents? Fertil Steril 2008; 90: 1769-73.  Back to cited text no. 3
    
4.
Cayan S, Akbay E, Bozlu M, Doruk E, Erdem E, et al. The effect of varicocele repair on testicular volume in children and adolescents with varicocele. J Urol 2002; 168: 731-4.  Back to cited text no. 4
    
5.
Bogaert G, Orye C, De Win G. Pubertal screening and treatment for varicocele do not improve chance of paternity as adult. J Urol 2013; 189: 2298-303.  Back to cited text no. 5
    
6.
Zelkovic P, Kogan SJ. The pediatric varicocele. In: Gearhart JP, Rink RC, Mouriquand PD, editors. Pediatric Urology. Philadelphia: WB Saunders, 2010. p. 585-94.  Back to cited text no. 6
    
7.
Kozakowski KA, Gjertson CK, Decastro GJ, Poon S, Gasalberti A, et al. Peak retrograde flow: a novel predictor of persistent, progressive and new onset asymmetry in adolescent varicocele. J Urol 2009; 181: 2717-22.  Back to cited text no. 7
    
8.
Diamond DA, Zurakowski D, Bauer SB, Borer JG, Peters CA, et al. Relationship of varicocele grade and testicular hypotrophy to semen parameters in adolescents. J Urol 2007; 178: 1584-8.  Back to cited text no. 8
    
9.
Cantoro U, Polito M, Muzzonigro G. Reassessing the role of subclinical varicocele in infertile men with impaired semen quality: a prospective study. Urology 2015; 85: 826-30.  Back to cited text no. 9
    
10.
Pasqualotto FF, Lucon AM, de GAM, PM, Sobreiro BP, Hallak J, et al. Is it worthwhile to operate on subclinical right varicocele in patients with grade II-III varicocele in the left testicle? J Assist Reprod Genet 2005; 22: 227-31.  Back to cited text no. 10
    
11.
Elbendary MA, Elbadry AM. Right subclinical varicocele: how to manage in infertile patients with clinical left varicocele? Fertil Steril 2009; 92: 2050-3.  Back to cited text no. 11
    
12.
Zheng YQ, Gao X, Li ZJ, Yu YL, Zhang ZG, et al. Efficacy of bilateral and left varicocelectomy in infertile men with left clinical and right subclinical varicoceles: a comparative study. Urology 2009; 73: 1236-40.  Back to cited text no. 12
    
13.
Cervellione RM, Corroppolo M, Bianchi A. Subclinical varicocele in the pediatric age group. J Urol 2008; 179: 717-9.  Back to cited text no. 13
    
14.
Zampieri N, Dall'Agnola A. Subclinical varicocele and sports: a longitudinal study. Urology 2011; 77: 1199-202.  Back to cited text no. 14
    
15.
Chen JJ, Ahn HJ, Junewick J, Posey ZQ, Rambhatla A, et al. Is the comparison of a left varicocele testis to its contralateral normal testis sufficient in determining its well-being? Urology 2011; 78: 1167-72.  Back to cited text no. 15
    
16.
Bong GW, Koo HP. The adolescent varicocele: to treat or not to treat. Urol Clin North Am 2004; 31: 509-15.  Back to cited text no. 16
    
17.
Paduch DA, Niedzielski J. Semen analysis in young men with varicocele: preliminary study. J Urol 1996; 156: 788-90.  Back to cited text no. 17
    
18.
Guarino N, Tadini B, Bianchi M. The adolescent varicocele: the crucial role of hormonal tests in selecting patients with testicular dysfunction. J Pediatr Surg 2003; 38: 120-3.  Back to cited text no. 18
    



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