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Clinical Focus
19 SEPTEMBER 2025 ausdoc. com. au
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Case Report
Teen testicular swelling
What to consider when investigating and treating varicocele in a teenager.
Dr Bhavesh Patel is a senior paediatric surgeon; state surgical champion clinical lead for quality improvement; health informatician; and educator at Children’ s Health Queensland, Clinical Excellence Queensland and Betterkids, Queensland.
ETHAN, aged 14, is brought in by his mother with concerns about swelling in the left testicular region. He is fit and well, plays AFL, and has not had any previous surgery.
On examination, Ethan weighs 52kg and is 164cm with a BMI of 19kg / m 2( 50th centile). He is a Tanner stage 3-4 male, with a grade 3 varicocele on the left. The left testis feels slightly smaller than the right. Abdominal exam is otherwise unremarkable, with no palpable masses.
Investigation
An ultrasound of the scrotum confirms the presence of the left varicocele. The volume of the right testis is 15mL, and left is 12mL. Abdominal ultrasound excludes a mass. There is mild narrowing of the renal vein between the aorta and superior mesenteric artery( known as nutcracker syndrome, see figure 1).
Further assessment
Ethan is referred to a paediatric surgeon. On further questioning, Ethan reveals he is experiencing dragging inguinoscrotal pain towards the end of the day, and that it is more pronounced after activity such as footy training and weekend matches.
Given the discomfort, treatment is recommended. Options discussed are laparoscopic ligation of the left gonadal vein, or interventional radiological embolisation of the left gonadal vein.
Ethan proceeds to undergo surgical correction with laparoscopic ligation of the gonadal vessels, as a day procedure under general anaesthetic. His symptoms and varicocele promptly resolve. He initially develops a small painless hydrocele; however, this resolves by the six-month check.
Discussion
Varicocele occurs in about 15 % of the adolescent population, 1 although a screening study has found occurrence can be as high as 28.5 % between the ages of 10 and 16 years. 2 It reflects the abnormal dilatation of the pampiniform venous plexus in the scrotum. The majority of cases occur on the left side, because the left gonadal vessels drain into the inferior vena cava( IVC) via the left renal vein, compared with the right gonadal vessels that drain directly into the IVC. This creates a higher pressure gradient that can result in varicosities( see figure 1).
Clinical grading is commonly performed using an iteration of the Dubin and Amelar classification from 1970( see table 1). 3, 4
There is an association between varicocele and subfertility. Observational studies have described changes to spermatozoa, including increased DNA fragmentation, reduced total sperm count, motility and vitality, and abnormal morphology. These changes are thought to be secondary to oxidative stress, scrotal hyperthermia and induced apoptosis. 5 In cases of male factor infertility, treatment of varicocele of any grade may improve sperm concentration, motility and morphology and conception rates. 6, 7
In adolescents, the indication for treatment is not so clear as for adults with male factor infertility. Only 20 % of those with varicoceles as adolescents will have issues with fertility in adulthood, and it is not well established that varicocele is the cause, as subfertility suggests abnormal right testicular function as well as the typically affected left.
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