Page 144 - Remedial Andrology

10.4.2.3 Recommendations for germ cell malignancy and testicular microcalcification

Recommendations Strength rating
Men with testicular microcalcification (TM) should learn to perform self-examination even Weak
without additional risk factors, as this may result in early detection of testicular germ cell
tumour (TGCT).
Do not perform testicular biopsy, follow-up scrotal US, measure biochemical tumour Strong
markers, or abdominal or pelvic computed tomography, in men with isolated TM without
associated risk factors (e.g., infertility, cryptorchidism, testicular cancer, and atrophic testis).
Testicular biopsy may be offered in infertile men with TM, who belong to one of the following Weak
higher risk groups: spermatogenic failure (infertility), bilateral TM, atrophic testes (< 12 mL),
history of undescended testes and TGCT.
If there are suspicious findings on physical examination or US in patients with TM with Strong
associated lesions, perform inguinal surgical exploration with testicular biopsy or offer
orchidectomy after multidisciplinary meeting and discussion with the patient.
Men treated for TGCT are at increased risk of developing hypogonadism, sexual Weak
dysfunction and cardiovascular (CV) risk. Men should be managed in a multi-disciplinary
team setting with a dedicated late-effects clinic.
Sperm cryopreservation should be performed prior to planned orchidectomy, since men Weak
with testis cancer may have significant semen abnormalities (including azoospermia).
Men with testicular cancer and azoospermia or severe abnormalities in their semen Weak
parameters may be offered onco-testicular sperm extraction (onco-TESE) at the time of
radical orchidectomy.

10.4.3 Varicocele
Varicocele is a common congenital abnormality, that may be associated with the following andrological
conditions:
• male sub-fertility;
• failure of ipsilateral testicular growth and development;
• symptoms of pain and discomfort;
• hypogonadism.

10.4.3.1 Classification
The following classification of varicocele [1439] is useful in clinical practice:
• Subclinical: not palpable or visible at rest or during Valsalva manoeuvre, but can be shown by special
tests (Doppler US).
• Grade 1: palpable during Valsalva manoeuvre.
• Grade 2: palpable at rest.
• Grade 3: visible and palpable at rest.

Overall, the prevalence of varicocele in one study was 48%. Of 224 patients, 104 had unilateral and 120 had
bilateral varicocele; 62 (13.30%) were grade 3, 99 (21.10%) were grade 2, and 63 (13.60%) were grade 1
[1686]. Worsening semen parameters are associated with a higher grade of varicocele and age [1687, 1688].

10.4.3.2 Diagnostic evaluation
The diagnosis of varicocele is made by physical examination and Scrotal Doppler US is indicated if physical
examination is inconclusive or semen analysis remains unsatisfactory after varicocele repair to identify
persistent and recurrent varicocele [1439, 1689]. A maximum venous diameter of > 3 mm in the upright position
and during the Valsalva manoeuvre and venous reflux with a duration > 2 seconds correlate with the presence
of a clinically significant varicocele [1690, 1691]. To calculate testicular volume Lambert’s formula (V=L x W x H
x 0.71) should be used, as it correlates well with testicular function in patients with infertility and/or varicocele
[1692]. Patients with isolated, clinical right varicocele should be examined further for abdominal, retroperitoneal
and congenital pathology and anomalies.

10.4.3.3 Basic considerations
10.4.3.3.1 Varicocele and fertility
Varicocele is present in almost 15% of the normal male population, in 25% of men with abnormal semen
analysis and in 35-40% of men presenting with infertility [1439, 1687, 1693, 1694]. The incidence of varicocele
among men with primary infertility is estimated at 35–44%, whereas the incidence in men with secondary
infertility is 45–81% [1439, 1694].

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