I. Varicocele in adults 1. It is the most common reversible cause of male infertility. 2.One third of men can develop infertility problem. 3.15% of men can have varicocele. 4.80% of men with varicocele can be fertile or asymptomatic. Clinical dilemma of varicocele 1. for asymptomatic adolescent males with varicocele and the last known fertility related condition 2. whether we can choose other methods besides surgery to benefit them 3. overview 1. incidence: Turkish Prevalence Study: 4000 boys aged 11-19 years, incidence 1%-11 percent. (Akby, 2000) Incidence of varicocele in adolescents: 15% incidence in more than 2000 boys. (Steeno, 1976) 2. Severity: Grade I-9% , Grade II-4% , Grade I-2% 3. Compared with other childhood urological diseases: prenatal hydrocele 0.5%, cryptorchidism 1%, hernia/synovial effusion 2%, varicocele 2-6%. 4. 20% of the varicocele is infertile and surgery can benefit 50% of them. Therefore, 1/10 adolescents can benefit from surgery. 4. Indications for surgery 1. Common criteria: discomfort and pain; severity; atrophy, testicular asymmetry; disease progression. 2.For adolescent patients:Bilateral, single testis, abnormal semen. 3.Reasons for choosing surgery: volume difference 36%, family choice 24%, symptomatic 10%, high grade 9%, abnormal semen analysis 6%, intra-testicular varicocele 3%, occurrence of contralateral hernia 2%. V. Severity and prediction 1. In 1997, Paduch reported that Grade II and III accounted for 75% and 22% of the surgical cases, respectively. 2. In patients with infertility due to Grade III varicocele, the postoperative improvement in sperm concentration and power was better than that of Grade I and II. However, the fertility rate did not change. VI. Problems related to testicular atrophy 1. Definition: Absolute values: Podesta-2cc volume difference, Kass-3cc volume difference Percentage difference: Parrott-10% volume difference, Sayfan-25% volume difference 2. Clinical examination Vernier caliper measurement, testicular measurement meter, ultrasound calculation of volume (animal experiments show that ultrasound measurement is more accurate) 3. Complexity issues: may not always be associated with varicocele, may improve spontaneously, accurate & continuous measurement 4.The relationship between adult spermatic varicocele and testicular atrophy: volume reduction is not associated with infertility. 5. It is not clear that adolescent varicocele is a continuous progressive disease. VII. Subclinical varicocele 1. The natural history is unclear, and 28% are reported to develop into clinical varicocele. 2. CHB study: 63 cases, defined by more than 2 veins greater than 2.5 mm (w/o Valsalva), 48 right, 3 left, 3 bilateral. 47 (75%) contralateral to clinical varicocele. VIII. Management of varicocele in adolescents Conservative treatment: correct in 90% of cases.