Adolescent versus adult varicoceles--how do evaluation and management differ?

IN the management of varicocele fertility is the overriding consideration. For the adult the concern is typically immediate, whereas for the adolescent preservation of future fertility is the primary objective. This fundamental difference largely determines the manner in which varicocele is managed. In the adult population prospective, observational management is uncommon. The majority of varicoceles will be discovered in the course of infertility evaluation and, in conjunction with an abnormal semen analysis, will warrant correction. Others will present as a result of symptoms or patient displeasure with the presence of a scrotal mass and these, too, are corrected. Incidentally discovered varicocele associated with normal semen parameters in an adult actively trying to conceive does not mandate followup. In addition, adult males with varicocele are not routinely followed for testicular disproportion which, if absent at presentation, rarely seems to develop. One group that is followed is those in whom varicocele was discovered in adolescence and who may warrant a semen analysis every 1 to 2 years. The situation is different for adolescents in whom varicocele is typically discovered early in puberty, or on routine examination or by the patients themselves. The future fertility status of these patients is unknown. What we do know is that 80% of adult males with varicocele will be fertile and, thus, a selective approach to the surgical management of adolescent varicocele has been advocated. Historically objective criteria for surgery have included varicocele grade, gonadotropin-releasing hormone stimulation studies, testicular disproportion and, more recently, semen analysis. Of these criteria testicular disproportion (hypotrophy) has been the most widely accepted. Our center and others have demonstrated that ultrasound calculated testicular volume measurements are more precise than those performed with orchidometers and, therefore, scrotal ultrasound has become a routine part of the initial evaluation at most major centers. It is less clear at what volume differential surgery is warranted and when is the optimal timing of intervention. In a study of adolescents with varicocele we found that when correlating