Varicocele in adolescents
Examine an adolescent with a varicocele correctly, monitor testicular volume, and know who needs surgery.
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Objectives
After this course you will be able to
- Explain the pathophysiology of varicocele and why it is mostly left-sided.
- Determine the clinical grade and perform the examination correctly.
- Measure testicular volume by ultrasound and calculate the volume differential.
- Know the indications for surgery and avoid unnecessary operations.
- Identify when an atypical varicocele (right-sided, sudden onset) needs further workup.
Key message: most adolescents with a varicocele do not need surgery. The main decision criterion is testicular growth, not the grade.
Basics
Varicocele in numbers
- ~15%of adolescent boys
- ~90%left-sided
- >20%significant volume differential
- rarebefore age 10
A varicocele is dilation of the veins of the pampiniform plexus. It is usually detected at the onset of puberty, at 10–15 years.
Basics
Pathophysiology
- The left testicular vein drains into the renal vein at a right angle, while the right one opens obliquely directly into the inferior vena cava.
- The left renal vein can be compressed between the aorta and the superior mesenteric artery (nutcracker phenomenon).
- Valve incompetence leads to venous reflux, blood stasis and increased testicular temperature.
- As a result, in some adolescents testicular growth lags behind and semen parameters may deteriorate.
Most men with a varicocele are fertile. The risk increases when testicular growth lags behind or semen parameters are impaired.
Diagnosis
Clinical examination and grading
The examination is performed in a warm room, standing and supine, with a Valsalva maneuver.
| Grade | Finding |
|---|---|
| I | Palpable only with Valsalva |
| II | Palpable at rest, not visible |
| III | Visible through the skin |
| Subclinical | Detected only on ultrasound; requires no treatment |
An isolated right-sided varicocele, a varicocele in a prepubertal child, or a varicocele that does not decompress when supine or appears suddenly requires abdominal ultrasound to rule out a retroperitoneal mass (for example, a kidney tumor).
Diagnosis
Measuring testicular volume
The decision is based on the ultrasound-measured volume of both testicles. An orchidometer (Prader) gives an estimate; ultrasound is more accurate.
- Volume = length × width × depth × 0.71 (Lambert formula).
- Volume differential = (larger testicle − smaller testicle) / larger testicle × 100%.
- A difference of more than 20% (or more than 2 mL) is considered significant.
- The difference should be confirmed not by a single measurement but by repeat measurement 6–12 months apart: testicular growth can be asynchronous during puberty.
Doppler ultrasound shows venous reflux. A high retrograde flow velocity is associated with a higher risk of testicular asymmetry, but on its own it is not an indication for surgery.
Diagnosis
Semen analysis
- May be useful for decision-making in an adolescent who has completed puberty (Tanner V).
- At least two analyses are needed, because the parameters vary.
- It is discussed sensitively with the adolescent and family and is not mandatory.
Treatment
Indications for surgery
- A small testicle with a varicocele: a volume differential of more than 20% that persists on repeat measurements.
- An additional condition affecting the testicle (for example, operated cryptorchidism).
- Bilateral palpable varicocele.
- Impaired semen parameters in a postpubertal adolescent.
- Symptomatic varicocele: pain, a feeling of heaviness.
If none of these are present, the adolescent is followed with examination and ultrasound every 6–12 months. After surgery, in most adolescents the smaller testicle catches up in size with the other one.
Treatment
Comparison of techniques
| Technique | Advantage | Disadvantage |
|---|---|---|
| Microsurgical subinguinal | Lowest risk of recurrence and hydrocele | Requires a microscope and experience, takes longer |
| Laparoscopic, lymphatic-sparing | Fast, convenient for bilateral cases | High risk of hydrocele if the lymphatics are not spared |
| Laparoscopic or open, ligation together with the artery (Palomo) | Low recurrence | High risk of hydrocele |
| Embolization | No incision | X-ray exposure, endovascular procedure, recurrence may be higher |
Lymphatic-sparing techniques (a microsurgical approach or laparoscopy with lymphatic dye) significantly reduce the risk of postoperative hydrocele.
Treatment
After surgery
- Return to school after 2–3 days, no strenuous sports for 2–3 weeks.
- Comparison of testicular volumes by ultrasound after 6–12 months.
- New scrotal swelling suggests a hydrocele and needs examination.
- The adolescent is taught testicular self-examination.
The pediatrician's role: examine the scrotum at routine adolescent visits, order abdominal ultrasound for an atypical varicocele, refer an adolescent with testicular asymmetry to a pediatric urologist, and protect the family from unnecessary worry.
Quiz
Quiz: Varicocele
Test yourself: choose one answer.
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A 14-year-old boy has a left grade II varicocele; on ultrasound the testicular volume differential is 8%, and he has no symptoms. What should be done?
There is no significant volume differential, no symptoms and no other indication. The adolescent is followed with examination and ultrasound.
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Which varicocele requires abdominal ultrasound?
An isolated right-sided varicocele, or one that does not decompress when supine, requires abdominal ultrasound to rule out a retroperitoneal mass.
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The left testicle is 12 mL and the right is 9 mL. What is the volume differential?
(12 − 9) / 12 × 100% = 25%. The difference exceeds 20%, but it should be confirmed by repeat measurement.
-
Which technique has the lowest risk of postoperative hydrocele and recurrence?
The microsurgical subinguinal approach spares the lymphatics and the artery, and has the lowest rates of recurrence and hydrocele.
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Which statement about varicocele is true?
Most men with a varicocele are fertile. The main decision criterion is lagging testicular growth on repeat measurements.
Course completed
Related articles for parents
Sources
- EAU Guidelines on Paediatric Urology, 2025: Varicocele in children and adolescents.
- Silay MS, Hoen L, Quadackaers J, et al. Treatment of varicocele in children and adolescents: a systematic review and meta-analysis from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel. Eur Urol. 2019;75(3):448–461.
This material is intended for medical professionals and is based on current clinical guidelines. Decisions about an individual patient are made by the treating doctor.