Detection and Management of Pediatric Conditions That may Affect Male Fertility

Geolani W. Dy, MD; Melissa Rust, MSPAC; Pamela Ellsworth, MD, FAAP, FACS

Disclosures

Urol Nurs. 2012;32(5):237-248. 

In This Article

Initial Evaluation and Physical Examination

Many stigmata of infertility can be found on careful physical examination, with an emphasis on the genital examination, which is especially important in the prepubertal population. Male genital development assessment includes penile size, urethral meatal location, testis size, and location in all males regardless of age. In the post-pubertal male, manifestations of hypogonadism may include underdeveloped secondary sexual characteristics, decreased male pattern hair distribution (axillary, body, facial, pubic), gynecomastia, and eunuchoid body habitus (arm span 5 cm or more greater than height). The Tanner scale (see Table 2) is used to assess sexual development, and in males, to assess pubic hair and genitalia, including scrotal development, testicular volume, and penile length.

Testis size should be compared to norms for the patient's age and general chronological development. Testicular volume can be measured using a simple ruler, an orchidometer, comparative ovoids, or in select cases, ul tra sonography (Taskinen, Taavitsainen, & Wikstrom, 1996). Assessment for a varicocele should occur while lying, standing, and with Valsalva maneuver. Although rare in prepubertal males, varicoceles (see Figure 1) may occur, and it is recommended that prepubertal males be examined in the standing position because the varicoceles tend to be Grade II or less (Vasavada, Ross, Nasrallah, & Kay, 1997). Although more difficult than in the adult population, careful examination may allow for detection of absence of the vas deferens in the prepubertal or adolescent male. Epididymal anomalies may be more difficult to identify.

Figure 1.

Scrotal Ultrasound Demonstrating Varicocele

Semen analyses are a cornerstone of the adult infertility evaluation but have limited availability for pediatric patients. The ability to obtain a semen analysis is dependent on patient maturity, as well as parent and physician level of comfort. In the adolescent male with a varicocele, serial measurement of testicular volume is thought to be useful in determining whether or not the varicocele is having an adverse effect on testicular function (Barthold, 2011). However, there is controversy as to the correlation between testicular volume and semen analysis. Haans, Laven, Mali, te Velde, and Wensing (1991) noted that left testicular growth failure in adolescents with a varicocele was only associated with a decrease in total sperm number, whereas Guarino, Tadini, and Bianchi (2003) concluded that the evaluation of testicular volumes during examination for varicocele in Tanner Stage V adolescents is not predictive for testicular dysfunction.

Laboratory studies often include semen analysis when acceptable, endocrine evaluation, and genetic testing. The American Urological Association (AUA) (2010) best practice guidelines on the optimal evaluation of the infertile male recommend that at least two semen analyses be obtained after a defined period of abstinence of two to three days. If the specimen is being collected through the use of a condom, it is important the condom does not contain substances that would be detrimental to sperm. In addition, the collection container should be kept at room or body temperature and should be examined within one hour of collection. The semen volume and concentration should be noted in addition to sperm morphology, motility, and progression.

Ultrasound, frequently utilized in the pediatric urologic evaluation, can be used for measuring testis size, assessing subclinical varicocele presence, and measuring testicular blood flow. Other components of the laboratory and imaging workup are discussed in detail under specific diagnoses.

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