Diagnosis and Management of Pediatric Varicocele: A Modern Update for the Practicing Pediatrician

Abstract

Purpose of Review: Pediatric varicoceles are common, yet the paucity of data on long-term fertility outcomes does not establish recommendations for conservative management and reassurance versus pediatric urology referral for consideration of surgical intervention. This review incorporates recent literature to generate pragmatic, objective methodology for the evaluation and management of pediatric varicoceles. Recent Findings: The initial evaluation of pediatric varicoceles includes focused history, physical exam, and use of an orchidometer or ultrasound for volume assessment. In early puberty, asynchronous testicular growth may be transient and monitored serially via ultrasound. Further workup may include semen analysis (SA), ultrasound of spermatic veins to determine peak retrograde flow (PRF), and hormonal analysis. Pediatric varicoceles may be managed with observation and reassurance or referral to pediatric urology for consideration of surgical intervention. In patients presenting before Tanner V stage, management is typically expectant, with pain warranting referral. Definitive indications for referral once Tanner V is reached include pain, undesirable appearance, bilateral varicoceles, persistent testicular atrophy, low total testicular volume (TTV), elevated peak retrograde flow on Doppler ultrasonography, persistently low total mobile sperm count (TMSC) on repeat SA, or infertility. Summary: Most pediatric and adolescent patients with varicocele may be reassured and monitored serially. Straightforward and objective assessment tools should be used when further workup is warranted, providing clear guidance on elevation of care from pediatricians to pediatric urologists.