If one day you notice a vague swelling in your testicles that worsens with standing and eases with lying down, beware of the possibility of varicocele. Varicocele is relatively uncommon in boys before the age of 10, but the prevalence rises to 8-16% during puberty. 15% of adolescents between the ages of 15 and 19 have varicocele, which is comparable to the prevalence in the adult male population as a whole. Professor Kolon from the Perelman School of Medicine at the University of Pennsylvania analyzed relevant literature from Embase, PubMed, and Google Scholar to provide a systematic overview of the diagnosis and treatment of varicocele in adolescents. Early diagnosis The following indicators are commonly used to evaluate fertility: varicocele score, testicular volume measurement, ultrasound of the spermatic veins, hormone level measurement, and semen analysis. For adults, abnormal results of hormone level measurement and semen analysis suggest that more serious lesions have occurred in the testes, and are generally not an early diagnostic option for adolescents who are still in the developmental stage. The varicocele score is categorized into three levels: Grade 1, varicocele can be palpated by increasing abdominal pressure, Grade 2, varicocele can be palpated when standing, and Grade 3, varicocele can be seen when standing. However, studies have shown that there is no significant correlation between them and testicular developmental abnormalities and they are not used as an indicator for surgical repair. Testicular volumetric measurements are considered by many physicians as an indicator of spermatogenicity. Some patients have recovered some degree of testicular atrophy after undergoing varicocele repair, suggesting a link between varicocele and abnormal testicular volume. The difference between left and right testicular volume is usually considered to be clinically significant if the difference is more than 10% (or more than 20% in some cases) or more than 2-3 ml. Paltiel et al. found that ultrasound measurements were more accurate than testicular measurements, and that the more accurate algorithm was volume = L x S x D x D x 0.71 (Lambert formula). However, there is some subjective error in ultrasound testicular measurements. The urologist can take a comprehensive view of which measurements to use for measurement, but it is important to note that the data from any single measurement should not be used as a reference for judging surgical treatment. It is important to note that in adolescents, serial measurements of testicular volume at multiple time points throughout puberty can yield clinically significant data. Surgical indications The management of the adolescent varicocele patient has been controversial. Although early varicocele repair can prevent infertility, most patients are not infertile because of varicocele. Surgical repair of varicocele would result in the inclusion of a large number of patients for whom surgery is not necessary, resulting in a waste of healthcare resources. Only by proposing effective inclusion criteria can varicocele repair be properly practiced in clinical settings. Many studies have discussed the selection of inclusion criteria from different perspectives. Some surgeons believe that a difference in testicular volume of 10% (or 20%) or more requires surgical intervention, but studies have shown that nearly 80% of patients with such a difference resolve spontaneously without surgical intervention. Poon et al. suggested that changes in testicular volume could be an indicator, but subsequent studies have suggested that surgical intervention is required only in cases of abnormally reduced testicular volume that is increasing in severity. There is a correlation between decreased testicular volume and abnormal semen analysis, and Paduch et al. found that patients with varicocele scores of 2 to 3 had poorer semen quality, higher venous reflux, and greater testicular atrophy. It is important to note that the standard grading of semen analysis in adolescents differs from the WHO criteria for adults. Patients with abnormal testicular volumes measured prior to semen analysis and small total testicular volume are at higher risk for abnormalities. Although endocrine disruption has been suggested in some patients, there is no consensus that testing for luteinizing hormone (LH), follicle stimulating hormone (FSH), testosterone, inhibin B, and antimullerian hormone (AMH) is indicated only for the evaluation of adult disease. The American Urological Association’s Committee on Optimal Decision Making in Male Infertility and the American Society for Reproductive Medicine’s Practice Committee give four inclusion criteria, but all are applicable to adults. Adolescent varicocele repair should be considered only in the presence of objective testicular volume loss. The European Association of Urology recently gave several references for varicocele that include the adolescent population: 1. Treatment should only be used in patients with varicocele who have clinically proven testicular abnormalities; 2. There is no evidence that infertile patients with normal semen analysis or patients with clinically asymptomatic varicocele benefit from treatment for varicocele; and 3. Treatment of varicocele should only be used in patients with clinically symptomatic varicocele, spermatozoa, and spermatogenesis. Varicocele repair should only be considered in patients with clinical symptoms of varicocele, spermatocytopenia, infertility for more than two years, or other unexplained causes of infertility. There are a number of surgical options for varicocelectomy, including transabdominal, retroperitoneal, inguinal microscopic, and laparoscopic arteriovenous ligation excision and flow restriction. Arteriovenous embolization and sclerotherapy are not considered surgical treatment options. The key to choosing surgical treatment is its ability to reverse the testicular atrophy and abnormal semen composition seen in adolescent patients with varicocele. Several studies have concluded that surgical treatment can improve the results of semen analysis to varying degrees, gradually restoring testicular volume and providing benefits in terms of fertility. As such, there is sufficient evidence to support surgical treatment in patients who meet the aforementioned guidelines. The main complications of varicocelectomy include syringomyelia, treatment failure or recurrence of the condition, and testicular atrophy. Syringomyelia occurs most often in patients who are not undergoing microscopic surgery, mostly due to inadvertent intraoperative ligation of the associated lymphatic vessels. Surgical microscopy allows the surgeon to clearly isolate the inguinal lymphatics and arteries and veins, which greatly avoids inadvertent ligation. Failure of treatment or recurrence of the disease is mainly related to the level of surgical operation and the use of the surgical microscope. It is recommended that the surgical operator separate the tissues from the lower part of the inguinal canal, which provides a good view of the operation and the path of the vein ligation. Injury or ligation of the testicular artery can cause testicular atrophy and spermatogenic epithelial damage, which can be avoided by surgical microscopy, laparoscopic magnification imaging, and intraoperative Doppler measurement. If the testicular artery is inadvertently ligated, the vas deferens artery provides most of the blood supply to the testis, and the patient should be informed of the risk of testicular atrophy in the event of a future vasectomy. In both adults and adolescents, subinguinal microscopic varicocelectomy has the lowest rate of postoperative complications. The advantages of microsurgical repair over open and laparoscopic surgery are even more pronounced, reducing the incidence of syringomyelia and recurrence of varicocele while improving semen quality. Other Treatments Although most physicians recommend surgical treatment options, percutaneous varicocele embolization remains a well-tolerated and cost-effective treatment. Studies have shown that it can increase sperm concentration, activity, and improve sperm morphology without altering the patient’s endocrine status. There is a high incidence of complications such as syringomyelia and a risk of radiation damage. Prognosis The goal of treating varicocele is to achieve reproductive success. Whereas with treatment during adolescence, ultimate fertility is not obtained until they reach adulthood. Several studies have demonstrated that microsurgical varicocelectomy is associated with a higher spontaneous pregnancy rate and a lower likelihood of disease recurrence, as evidenced by the META score. Some researchers have proposed to study the endocrine profile of patients before and after surgery. Some studies have shown some increase in testosterone levels and increased FSH responsiveness regulated by GnRH in postoperative patients. However, most endocrine levels.