New onset bilateral or right-sided varicoceles are commonly symptomatic in adults and have been associated with retroperitoneal malignancy and less commonly, to anatomic malformations such as situs inversus. In adolescents, varicoceles are usually an incidental finding and little has been written about the presence of right sided varicoceles. Convention dictates that abdominal imaging be performed to rule out malignancy. We reviewed our varicocele database to characterize this subpopulation of adolescent varicoceles and to assess the utility of abdominal imaging.
The outpatient records were reviewed of all varicocele patients (ICD-9 456.4) seen from 2007-2011 with clinically palpable isolated right or bilateral varicoceles at diagnosis. Exclusion criteria were: incomplete information at diagnosis, age > 20 years, and subclinical varicoceles. Imaging studies (abdominal-pelvic CT or ultrasound) were reviewed for the presence of intraabdominal masses or renal vein thrombus. Testis volume was calculated by sonographic measurements using Lambert's equation, or estimated by Prader orchidometer. Testis symmetry was represented as percent contribution to total testis volume.
Among 1973 varicocele patients seen during the study period, 37 (1.9%) patients with bilateral varicoceles and 8 (0.4%) patients with isolated right sided varicoceles were identified. All varicoceles were asymptomatic and reduced when supine. Mean age at presentation was similar for both groups: 14.7 ± 1.7 yrs (bilateral) vs. 14.9 ± 2.7 yrs (right). Mean follow-up was also similar: 1.2 ± 1.3 years (bilateral) vs. 0.96 ± 1.9 months (right). Varicocele grade in isolated right sided patients was evenly divided between grades 1 (50%) and 2 (50%). Varicocele grade among bilateral cases was always more severe on the left side with the majority presenting as R2L3 (38%), R1L2 (19%), R1L3 (19%), and R1L1, R2L2 and R3L3 (8% each). Only 1 patient (bilateral case) demonstrated significant testicular asymmetry; the left testis contributed <40%, but increased to 49% at last follow-up. Abdominal and pelvic imaging was performed in 17 cases (12 bilateral and 5 right sided). There were no abnormal findings on any of the15 ultrasounds or 2 non-contrast CT scans to suggest retroperitoneal mass, vascular malformation or situs inversus.
Right sided varicoceles, whether isolated or bilateral, are unusual, incidentally found, low grade, and not associated with significant hypotrophy. The etiology is idiopathic as associated intra-abdominal or pelvic masses or anatomic anomalies were not detected by imaging. If a screening imaging study is considered, abdominal and pelvic ultrasound is adequate to rule out the possibility of malignancy without exposing the patient to unnecessary radiation.