Clinical Outcome of Adolescent Sub-Clinical Varicoceles from a Single-Institution Experience
Patricia S. Cho, MD1, Richard N. Yu, MD, PhD2, Harriet Paltiel, MD2, Matthew Migliozzi, MA2, Xiaoran Li, MS2, Alyssia Venna, MBS2, David A. Diamond, MD2.
1University of Massachusetts Medical School, Worcester, MA, USA, 2Boston Children's Hospital, Boston, MA, USA.
BACKGROUND: Subclinical varicoceles represent an ultrasonographic abnormality of the veins of the pampiniform plexus detected during scrotal ultrasound. Although there is no consensus on a precise definition, the diagnosis is often based on the presence of venous dilatation and/or retrograde venous blood flow in the absence of a clinically palpable varicocele on the ipsilateral side. As the significance of this typically incidental finding is unclear and clinical management is variable, the objective of this study is to determine the characteristics and outcomes of patients with subclinical varicoceles diagnosed in a tertiary care center, focusing on resolution and progression rates.METHODS: We performed a single-institution retrospective review of all patients with the diagnosis of subclinical varicocele between October 1999 through October 2014. Information obtained included age at diagnosis, ultrasound findings, ultrasound measured testis dimensions, clinical examination findings, and duration of varicocele resolution or progression. Ultrasounds were reviewed by a single radiologist. Subclinical varicoceles were defined by ultrasound findings of dilatation of the pampiniform venous plexus involving 2 or more vessels with vessel diameter > 2.5mm (with or without Valsalva) without clinical evidence of a varicocele on physical exam or history of prior inguinal surgery.RESULTS: Ninety-eight patients were designated as having a subclinical varicocele. Thirty-four were excluded due to misclassification with clinical varicoceles, with another 3 for prior inguinal surgery. Another 4 patients did not have US images available for review, with 19 having insufficient information on US studies. Two patients did not meet US criteria for varicocele on review. Thirty-six patients were confirmed to have subclinical varicocele for further analysis. The mean age at initial visit was 15.5 years old (range 8.8-21.5 years) with mean follow-up of 26.5 months (range 1-86 months). Twenty-five (69%) had a subclinical varicocele on the right, 8 (22%) on the left, and 3 (8%) bilateral. Twenty-four patients (66%) had a contralateral clinical varicocele. The majority of patients (81%) did not have testicular asymmetry on initial US, though 5 (14%) had asymmetry on initial US which was persistent in only 1 patient. 17 patients had both follow-up examinations and US, with only 3 patients (18%) progressing to clinical ipsilateral varicocele. None of these patients underwent surgery or demonstrated asymmetric testicular volume with the duration of recorded follow-up. The majority remain either subclinical (53%) or have resolved (29%) without requiring surgery for the ipsilateral side.CONCLUSIONS: Subclinical varicoceles are a relatively uncommon incidental finding with limited information on long-term outcome, owing in part to challenges in both diagnosis and management. Most subclinical varicoceles in our study were right sided and identified in patients with a contralateral clinical varicocele, emphasizing an incidental nature. In contrast to prior studies, our results suggest that subclinical varicoceles are unlikely to progress to clinical varicoceles or require surgery. Although their clinical significance remains unclear, they do not appear to have an impact on testicular volume upon serial follow-up. While our study is limited by small numbers and follow-up, this information may aid in formulating a clinical management strategy and guide future prospective studies.
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