What is the treatment for a 15-year-old male with a left-sided varicocele (enlargement of the veins in the scrotum) of the left testis and bilateral epididymal head cysts?

Treatment for Adolescent with Left-Sided Varicocele and Bilateral Epididymal Head Cysts

For a 15-year-old male with left-sided varicocele and bilateral epididymal head cysts, the recommended approach is conservative management for the epididymal cysts and surgical intervention (preferably microsurgical varicocelectomy) for the varicocele if it is grade 3 (palpable) with documented testicular atrophy or abnormal semen parameters. 1

Initial Evaluation

• Diagnostic workup should include:
  • Physical examination to determine varicocele grade (1-3)
  • Scrotal ultrasound to:
    • Confirm varicocele presence
    • Measure testicular volumes to assess for asymmetry
    • Characterize epididymal cysts (size, location)
    • Measure peak retrograde flow (PRF) in the varicocele
  • Consider semen analysis if sexually mature (two samples, one month apart)
  • Hormonal evaluation (testosterone, FSH, LH) to assess testicular function

Management of Varicocele

Decision Algorithm for Varicocele Treatment:

1. Indications for surgical intervention:

   • Grade 3 (palpable) varicocele WITH:
     • Documented decrease in testicular size (≥20% asymmetry)
     • Abnormal semen parameters
     • Pain or discomfort
     • Peak retrograde flow >38 cm/s

2. Consider close monitoring if:

   • 10-20% testicular volume asymmetry
   • 30-38 cm/s peak retrograde flow
   • Mild sperm abnormalities

3. Conservative management if:

   • PRF <30 cm/s
   • Testicular asymmetry <10%
   • No sperm or hormonal abnormalities

According to the American Urological Association guidelines, early treatment of grade 3 varicocele with testicular atrophy is recommended to prevent further decline in testicular function and preserve future fertility potential 1.

Surgical Options for Varicocele:

• Microsurgical varicocelectomy (preferred approach):

  • Improves semen parameters in 60-70% of cases
  • Preserves testicular artery
  • Lower risk of recurrence and complications

• Laparoscopic varicocelectomy:

  • Good alternative, especially if previous inguinal surgery
  • Allows preservation of testicular artery
  • Typically outpatient procedure 2

• Sclerotherapy:

  • Less invasive alternative
  • Typically used for small to medium veins or recurrent varicocele

Management of Epididymal Cysts

Epididymal cysts are generally benign and asymptomatic, requiring treatment only if symptomatic or very large.

Treatment Algorithm for Epididymal Cysts:

1. Conservative management (recommended for asymptomatic cysts):

   • Regular monitoring with ultrasound
   • No intervention needed unless complications develop 3

2. Intervention indicated only if:

   • Symptomatic (pain, discomfort)
   • Large size (>5 cm)
   • Complications (torsion, infection)

3. Treatment options if intervention needed:

   • Percutaneous sclerotherapy:

     • Less invasive than surgery
     • Effective for symptomatic cysts >5 cm
     • Uses sclerosing agents like Polidocanol
     • 84% success rate with low complication risk 4

   • Surgical excision:

     • Reserved for complicated cases or when sclerotherapy fails
     • Higher risk of complications

Follow-up Recommendations

• Ultrasound evaluation 3-6 months after varicocele treatment to assess:

  • Testicular size (catch-up growth)
  • Varicocele resolution
  • Status of epididymal cysts

• Repeat semen analysis 3-6 months after treatment if initially abnormal

• Consider sperm banking before any intervention, especially if significant testicular volume loss is present 1

Important Considerations

• The frequent association between epididymal cysts and varicocele in adolescents is likely due to coincidence of both pathologies in the prepubertal age 3

• Torsion of epididymal cysts is extremely rare but can cause acute scrotal swelling requiring emergency intervention 5

• Complete recovery of lost testicular volume is unlikely after varicocele repair, emphasizing the importance of early intervention when indicated 1

• IVF with ICSI may be considered alongside or instead of varicocele repair for future fertility concerns, especially in cases with significant testicular damage 1