Varicoceles in Children and Adolescence: When and How to Treat?

White blonde little boy around six at the doctor's office. He is with his mom behind him and the doctor is in front of him, examining him and discussing varicoceles in children.

By Andrew J. Kirsch, MD, FAAP, FACS

Physicians and parents alike are challenged by the management of varicoceles in children.  This blog is meant to frame the controversy and educate our patients and families on the current state of the art.  As will soon become obvious, shared decision-making is particularly important when considering the many questions that 15% of the male population and their parents need to consider. The first question below is a big question and charged in controversy.

Do adolescent varicoceles have a progressive harmful impact on male fertility?

 

A graph for varicoceles in children. Five blue text boxes in a row. The first says "adolescent varicoceles", the second says "testicular volume", the third says "semen parameters", the fourth says "hormone alterations", and the fifth says "male fertility". Each box has an arrow pointing to the next, and, to the left is a swooping line that includes all of the boxes with a question mark in the middle.

Determining the effect on future fertility is challenging for a variety of reasons

  • Limitations in obtaining/interpreting semen analysis
  • Unequal differential testicular growth during puberty regardless of varicocele
  • A long lag time between varicocelectomy and attempt at paternity
  • To add to the confusion, there are no current professional guidelines for children and adolescents

There are 2 main debates among expert pediatric urologists.  The first is whether we should treat a varicocele surgically.  Here are the issues:

The debate to treat is supported by these facts:

  • Varicocele is the most common correctable cause of male infertility
  • Corrective surgery (varicocelectomy) improves semen quality

The debate not to treat is also supported by facts:

  • Men with varicoceles father children
  • Semen quality does not always mean there be a successful pregnancy

The second debate focuses on when to treat a varicocele. Here are the pertinent questions:

Do we treat all adolescents with large varicoceles and smaller testis on the same side?  If so, would we overtreat? Or, do we wait and only treat the infertile man trying to start a family? If so, are we too late? Will success be lower? These are the questions that are likely to torment parents of boys with varicoceles.

Here is some data that may help

In the pediatric age patient, the size or volume of the affected (left) testis compared to the normal side is key to helping identify who is at risk for future infertility.  Or is it?  There are many studies on both sides of this long-standing debate. Larger testis volume differences are associated with significantly lower sperm concentration and motility regardless of patient age or varicocele grade.  What is the testis volume loss of boys with varicoceles compared to boys without varicoceles?  A study looking at >400 affected boys compared to 70 normal boys showed that those with grade 3 varicoceles had left testis volume loss at all stages of puberty, but also right testicular volume loss compared to controls. In other words, both testes can be affected.

Many studies show that varicoceles are not progressive – they don’t get worse – and catch-up growth occurs without surgery.  However, in one study of 100 boys with an average age of 15 years, testicular volume differences > 20% lead to 2x odd of a lower total mobile sperm count.  The same study showed total testicular volume (TTV = right + left) <30cc lead to a 4x odds of a lower sperm count.  Almost all studies have shown that there does not appear to be any association between testicular volume loss and hormone abnormalities.

So, we have decided that surgery would be the best approach.  Is there a difference in outcomes?

When deciding upon differences in surgical approach – laparoscopic (Palomo), microscopic, or open groin incision, there is no good data to support one approach over another.  The rates of hydroceles (fluid around testis) or recurrence are generally low (<10%).

Let’s summarize Varicoceles in Children:

The dilemma regarding pediatric varicoceles comes down to these facts:

  • Our tools to identify subfertility are imperfect
  • Your urologist needs to evaluate all meaningful data
    • Testis size (TTV <30cc, TVD >20% )
    • Semen analysis when available
    • Status of “normal” testis
    • Hormone levels (not meaningful in young age)

Parental preference is key.  There’s no doubt about it – shared decision-making is critical to the management of varicoceles.  Advice to parents:  For the majority of boys with varicoceles it makes good sense to follow prospectively and treat conservatively.

Can a Child with UTIs have Reflux?

Urologist and child patient are happy after finishing up treatments for VUR and UTIs.

By Dr. Michael Garcia-Roig

Urinary tract infections (UTI) can occur in children, as well as adults. This happens when bacteria normally living in the bladder grows out of control and irritate the bladder’s lining, causing symptoms like painful urination, having to run to the bathroom often, urine accidents, or blood in the urine.

If you find yourself asking can a child get a UTI or VUR, keep reading below.

What Causes UTIs in Children?

In young kids, a few common behaviors can cause urinary infections. Specific behaviors that put kids at risk for UTI are not urinating often, not drinking enough liquids, and ignoring a full bladder or the urge to urinate withholding behaviors like the “pee-pee dance” or holding the genitals. Constipation also plays a huge role in UTI’s, especially in kids. It doesn’t take long for the rectum to get full in kids. With the pelvis being small, the full rectum can get in the way of the nerve signals to the brain, or in the worst cases, it can even directly pinch the bladder and make it hard to empty.

What Causes VUR?

Normally, urine made by the kidneys comes down a small tube, called the ureter, to the bladder. This is intended to be a one-way trip- once urine makes it to the bladder it can’t go back up to the kidney. Vesicoureteral reflux, or VUR, happens when urine can freely flow back and forth between the bladder and kidney. In some people, this back and forth flow of urine can cause a small bladder infection to quickly turn into a miserable kidney infection. In kids with VUR who get kidney infections, especially those that get lots of them, long term kidney damage can happen.

Sometimes the bacteria causing a bladder UTI can make their way up to the kidney, causing a kidney infection, also called pyelonephritis. These kidney infections can be very severe in some children and are most commonly signaled by a UTI with a fever. There are several reasons why kids can get pyelonephritis, but this article will focus on the most common reason, vesicoureteral reflux.

How Do You Treat UTIs in Children?

The first step in managing a UTI is to get a urine sample before starting antibiotics to see what is causing the problem and what is the best medicine. Urine samples after antibiotics may give a false negative result. In kids who are not potty trained, this is done by passing a catheter into the bladder to get a clean sample of urine. Specimen collection bags that can be taped to the groin are good for checking the urine for a lot of things, but not for checking for urinary infection as they are very, very unreliable.

For children 2-24 months old with their first febrile UTI, the American Academy of Pediatrics recommends getting an ultrasound of the kidneys and bladder to rule out major kidney problems. Further testing is not recommended unless problems are noted on the ultrasound, or until a second UTI with fever happens.  At that time, your doctor will order a test called a voiding cystourethrogram, or VCUG, to look for vesicoureteral reflux or VUR. Vesicoureteral reflux is the medical way of saying urine goes from the bladder up to the kidneys. The VCUG is done by passing a small tube, called a catheter, through the urethra and into the bladder. The bladder is filled with x-ray contrast and x-rays are taken to see how the bladder and urethra look, and if contrast stays in the bladder, or goes up to the kidneys.

How Do You Treat Vesicoureteral Reflux in Children?

If vesicoureteral reflux is found after a febrile UTI, there are a few options for treatment. Sometimes a daily low dose antibiotic is started to prevent more kidney infections. In some kids, VUR will go away on its own as he or she grows. This usually takes one, two, or more years and a VCUG is repeated every year until its gone. Your doctor may be able to estimate the likelihood it will resolve in your child.

VUR can also be corrected with surgery. There are two basic approaches to surgery. First involves passing a small camera into the bladder through the urethra, and a small needle is used to inject a sugar-based substance called Deflux just under the ureter. In our hands, this stops reflux and infections 90-95% of the time. Kids go home the same day, there are no cuts, and there is typically little discomfort. Another way to fix VUR is called ureteral reimplantation. This surgery tucks the ureter into the side of the bladder and stops reflux and infections 95% of the time. It requires a small cut near the pubic bone, and kids stay in the hospital 1-2 nights. In some kids, a surgical robot can also be used to do ureteral reimplantation with similar outcomes and less pain.

There isn’t a one size fits all treatment for VUR, as each of these treatment options has its own pros and cons. What does need to happen is the prevention of kidney infections. Your doctor will go over options with you in detail to help find the best way to treat your child.

If you’d like any additional information on the question can a child get a UTI or VUR, click here to contact any of Georgia Urology’s expert pediatric urologists.

Hydroceles in Kids: What Parents Should Know

child getting checked for hydroceles

By Dr. Michael Garcia-Roig, M.D

The scrotum is the sack behind the penis where the two testicles live in males. Occasionally, some babies and older children can develop painless swelling in this area. It can come on quickly or slowly and can be constant or can come and go.

There are several reasons why the area can become swollen including a hydrocele or an inguinal hernia, varicocele, spermatocele, swelling from an insect bite, and rarely, testicular cancer.

We’re going to talk about hydroceles in kids.

What are Hydroceles?

The most common cause of painless scrotal swelling in kids is a hydrocele or collection of fluid around the testicle. Hydroceles can be communicating or noncommunicating, meaning the fluid in the scrotum freely flows in and out of the scrotum (communicating) vs only staying in the scrotum (noncommunicating).

The hydrocele fluid gets to the scrotum through an opening in the groin, called a patent processus vaginalis or a hernia. The processus vaginalis is part of normal development in babies. It’s supposed to go away at or soon after birth but stays around in some kids.

Can Hydroceles Be a Serious Condition?

The opening of the processus vaginalis is usually small, just letting fluid in and out, but sometimes it can be large or become large later in life. Larger openings are worrisome because they can let things from the abdomen, like intestines, fall into the scrotum and become strangulated, cutting off blood flow to that section of intestine. This is an emergency.

Our goal is to fix a patent processus vaginalis before this complication occurs if the opening doesn’t go away on its own in babies, or if it contains more than just fluid.

How are Hydroceles Diagnosed and Treated?

There are some tests to diagnose a hydrocele or a hernia. Often, a doctor can make the diagnosis by just examining a child. Sometimes an ultrasound helps get more information when a physical exam isn’t clear or the other conditions listed above are suspected.

Hydroceles and hernias are fixed with surgery, which is done in the hospital operating room under general anesthesia. In children, unlike adults, hernia repair does not require the use of any mesh products. Complications like bleeding, infection, or a recurrent fluid collection around the testicle are rare. Kids typically go home the same day.

If you have any more questions regarding hydroceles, contact the pediatric urology experts with Georgia Urology.

Your Child’s Risk of Testicular Torsion

By Dr. Michael Garcia-Roig

 

Male toddle who is playing with a toy car.

Sudden onset testicular pain can be a medical emergency. There are a number of things that can cause this, but one of the most concerning involves a sudden twisting of the testicle that cuts off blood flow to that area. This problem happens in some kids because the testicle isn’t held in place correctly, allowing it to spin on its stalk. If the testicle twists enough times, it can cut off blood to that area. Left undiagnosed and untreated, this can result in loss of the testicle.

Causes

Torsion of the testicle typically occurs around the time of puberty, in males 10-25 years old, and sometimes happens a few hours after rough physical activity, minor trauma to the area, or even in the middle of the night while sleeping. The pain is usually severe, typically doesn’t go away, and can be associated with nausea or feeling like you’re going to throw up.

Treatment

It’s important to see a doctor emergently for sudden and significant testicular pain because there’s more than one reason this pain can happen. If your doctor suspects a testicular torsion, they may get more tests, like an ultrasound of the testicles. If the testicle is twisted, it can usually be saved if diagnosed and treated within 4-8 hours from onset of pain. Treatment involves surgery to untwist the testicle and secure it to the inside of the scrotum so it can’t move. Generally, if the pain has been going on for more than 12 hours, there is a good chance the twisted testicle can’t be saved and will need to be removed. Your doctor won’t know for sure until they’re doing the surgery. The normal untwisted testicle on the other side is also secured to the inside of the scrotum to prevent it from twisting. If the testicle has to be removed, your doctor may be able to put in a prosthetic testicle, or fake testicle, at the time of surgery or at a later date to give the appearance of two testicles.

Even if the pain goes away, it’s a good idea to get checked out because it’s possible for the testicle to twist and untwist on its own. If this happens and is confirmed with tests, your doctor may recommend surgery to secure the testicle to the inside of the scrotum so it can’t move.

Prevention

Unfortunately, testicular torsion can’t be prevented. It happens because the testicle isn’t secured to the inside of the scrotum correctly and this can’t be diagnosed with imaging studies like an MRI or ultrasound. The most important thing to keep in mind is to get your child examined by a doctor if there is a sudden onset of severe testicular pain accompanied by tenderness, swelling, and nausea.

If you suspect testicular torsion is happening to your child, contact the trusted pediatric urologists at Georgia Urology.