Natural history of testicular size in boys with varicoceles

Abstract

Introduction: Testicular size is commonly used as a proxy for future fertility in adolescent boys diagnosed with varicoceles. Surgery is often performed based on a 15-20% reduction in volume of the ipsilateral testicle when compared to the unaffected side. Recent European Association of Urology guidelines, however, have highlighted the risk of overtreatment. Data on the natural progression of testicular size discrepancy are limited in this population. To evaluate the role of a non-surgical approach, the present study reports on testicular size progression in 35 boys with left-sided varicoceles managed with observation alone.

Methods: In the present study, 103 consecutive boys who were seen for varicocele were retrospectively evaluated; the 35 who were seen for at least three sequential visits by the same pediatric urologist for a unilateral left varicocele were selected. In the present practice, surgical management of varicoceles in teens is offered, but not recommended unless surgery is being performed for another reason (3/103). The Prader orchidometric testicular volumes that were documented for all visits were recorded and the volume of the left testicle as a percentage of the right was calculated. This analysis was performed for the entire population, and subgroup analysis was conducted for boys with a Grade 3 varicocele, with >10% asymmetry at diagnosis, and by dividing the population into prepubertal and pubertal age groups. Boys with bilateral varicoceles, concurrent testicular masses, or volumes recorded by a nurse practitioner were excluded from the study.

Results: The mean left testicular volume in the population was found to measure 96%, 95% and 96% of the right at the first, second and third visit (median interval was 2.0 years), respectively. Among the 26 boys seen for a fourth visit (median 3.3 years) and the 15 seen for a fifth visit (median 4.3 years), the mean left testicular volumes were 98% and 97% of the right at diagnosis and 97% at both the fourth and fifth visits (Figure). Likewise, no differences were seen after dividing the population into prepubertal (9-11 years, n = 9) and pubertal (12-14 years, n = 26) groups. Among the 13 (37%) boys with a Grade 3 varicocele at presentation, the left testicular volume was 95% (SD 11.4) of the right and remained unchanged by the third visit (96%, P = 0.69). In addition, among the 11 boys (31%) with greater than 10% size difference at the first visit, the left testicle measured 82% of the right (SD 5.3) at diagnosis and increased to 92% (SD 6.3) by the third visit (P < 0.001).

Discussion: In the 35 boys observed over a median of 2.0 years or three consecutive visits, there was no worsening of testicular asymmetry. This finding is consistent with some previous observational data on pediatric varicoceles, but carries the advantages of a narrower age range and longitudinal follow-up in all patients. At the same time, these results differ from other studies that show no improvement or worsening of asymmetry during follow-up. This difference is attributed to the inherent characteristics of the present study population and the choice of orchidometer for measurement. The present data have the advantage of excluding selection bias. Recognizing that this study is a retrospective, single-operator study with a small sample size, prospective, randomized trials are recommended to weigh surgery vs observation in adolescent varicocele patients.

Conclusions: No progression in atrophy/hypotrophy of the left testis was found in a series of 35 consecutive patients who were followed non-surgically for left-sided varicocele. Our data thus support observation as management for childhood varicocele in younger teens.

Keywords: Adolescent; Asymmetry; Observation; Testis; Varicocele.