Can adolescents with varicocele undergo surgery?

Author: Zhang Xing, chief physician of Yangzhou Traditional Chinese Medicine Hospital

Reviewer: Chen Yun, Chief Physician, Jiangsu Provincial Hospital of Traditional Chinese Medicine

Varicocele in adolescents may affect their reproductive function in adulthood. Therefore, intervention measures should be taken early and surgical treatment can be considered if necessary.

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1. Causes of varicocele in adolescents

Varicocele rarely occurs in boys under the age of 10, but the incidence increases from the early puberty (about 10%). The specific cause of varicocele during this period is still unclear, but it is generally believed to be related to the obstruction of blood return from the spermatic vein. When the venous blood return is not smooth, it is easy to cause the return blood to accumulate, thus causing varicose veins.

There are two reasons for the obstruction of spermatic vein blood return in adolescents, namely problems with the spermatic cord itself and other diseases or non-disease factors.

1. Problems with the spermatic cord itself

If the connective tissue around the spermatic cord is relatively weak, the venous wall lacks elasticity, the cremaster muscle is underdeveloped, the spermatic venous valve is defective or incompletely closed during the growth and development period, the blood return of the spermatic vein may be obstructed.

2. Other diseases or non-disease factors

When the left renal vein is compressed, it may also cause obstruction of the spermatic vein blood return, leading to varicocele, that is, symptomatic varicocele. For teenagers, the most likely factor to cause obstruction of the spermatic vein blood return is the nutcracker syndrome.

Nutcracker syndrome is a disease in which the left renal vein is squeezed when it merges into the inferior vena cava, causing clinical symptoms such as hematuria. The disease has a high incidence in children or adolescents, and mostly occurs in males.

Under normal circumstances, the left renal vein is not squeezed when passing through the angle between the abdominal aorta and the superior mesenteric artery. However, during puberty, the rapid growth of adolescents' height, the reduction of fat tissue at the origin of the superior mesenteric artery, the sagging of abdominal organs and the overstretching of the spine cause the angle between the two to become narrow, thereby squeezing the left renal vein and causing obstruction of blood return in the spermatic vein.

Similar to the location of varicocele in adults, most adolescent varicocele occurs on the left side, less than 20% of patients have bilateral varicocele, and it is rare for only the right side to be affected.

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2. Clinical symptoms and hazards of adolescent varicocele

Varicocele is generally divided into two types: subclinical and clinical.

1. Subclinical

No varicocele was found during the external examination, but laboratory examination revealed slight varicose vein.

2. Clinical type

It can be divided into three levels. Level I: No varicocele is found during palpation, but the doctor can find varicocele through the specified movement test; Level II: No obvious abnormality is found during visual examination, but varicocele can be found during palpation; Level III: Extremely obvious varicocele can be found during visual examination or palpation.

Most adolescent varicoceles are subclinical and do not cause any discomfort in daily life. Ultrasound examinations can reveal that blood stasis or reflux may occur in the veins, the inner diameter of the blood vessels may increase, and the testicles may be underdeveloped.

A very small number of adolescent varicocele are clinical, and adolescents can find that one side of the scrotum is swollen, especially when taking a warm bath. Sometimes there is a feeling of heaviness and dull pain in the scrotum, which will be aggravated if they exercise too much or stand for too long.

During the clinical appearance examination, the scrotum on the side with varicose veins is significantly lower than the normal side, and there are light blue dilated and tortuous vascular plexuses on the superficial skin. When touched by hand, the varicose veins are like lumps of earthworms. After lying down or gently pressing, the varicose veins will shrink or disappear, but then recover or appear again.

Varicocele can cause the following two hazards to adolescents.

1. After varicocele occurs, local blood flow changes, temperature rises, and the function of supporting cells in the testicles is damaged, which may lead to spermatogenesis disorders and even affect fertility in adulthood.

2. When the varicocele becomes varicose, it will reduce the secretion function of testicular androgen, causing male hormone deficiency. In severe cases, it may even lead to testicular atrophy in adolescents.

3. Which patients are suitable for surgical treatment?

Mild varicocele is generally treated with observation, regular follow-up to the appropriate age, and semen examination if necessary to determine whether the patient needs surgical treatment. When the varicocele is severe and causes physical or psychological discomfort to adolescents, surgical treatment can be considered.

Microscopic varicocele ligation is the best surgical method for treating adolescent patients and has been widely recommended both at home and abroad. There are five situations in which adolescent patients are suitable for surgical treatment.

1. Testicular volume reduction (the volume of the affected testicle is 2 ml or 20% smaller than that of the contralateral testicle).

2. Other testicular problems that may affect reproductive function are found.

3. Pathological changes in semen quality (older adolescent patients).

4. Varicocele was found on both sides.

5. Symptomatic varicocele.

In addition, when performing surgical treatment on adolescent patients with varicocele caused by Nutcracker Syndrome, due to the high recurrence rate, treatment should be carried out according to the specific conditions of the adolescent patients, for example, patients who have been observed for more than 2 years or have received symptomatic treatment, but whose symptoms have not been relieved or are still aggravated; patients who have complications such as dizziness, backache and fatigue; patients with renal impairment, etc. For adolescent patients in the above situations, only surgical treatment is needed, followed by follow-up observation.

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Although adolescent varicocele is not life-threatening, its adverse effects and consequences should not be underestimated. If a child is found to have symptoms related to varicocele, parents must take them to the urology or andrology department of a regular hospital for examination and treatment to avoid affecting their normal life in adulthood.

References

[1] Sun Yinghao. Wu Jieping. Urology[M]. Beijing: People's Medical Publishing House, 2019.

[2] Ni Xin, Sun Ning, Wang Weilin. Zhang Jinzhe Pediatric Surgery[M]. 2nd edition. Beijing: People's Medical Publishing House, 2020.