What are the treatment options for varicocele and potential next steps in management, including the possibility of compression of the gonadal vein in the abdomen?

From the Guidelines

Varicocele treatment involves several options depending on severity and symptoms, and the most effective approach is often embolization, which blocks blood flow through the affected veins, as shown to be effective in relieving orchialgia in 87% of patients at 39 months 1.

Treatment Options

• For mild cases, conservative management with regular monitoring is recommended.
• If you experience pain or fertility concerns, surgical intervention may be necessary, with options including open surgery (varicocelectomy), laparoscopic repair, or embolization.
• Post-procedure, rest for 1-2 days, avoid heavy lifting for 1-2 weeks, and use supportive underwear to reduce discomfort.
• Pain medication like acetaminophen (500-1000mg every 6 hours as needed) can help manage post-procedure pain.

Special Considerations

• If your condition involves compression of the gonadal vein in the abdomen (Nutcracker syndrome), additional evaluation with CT or MRI may be needed, and treatment might require stenting of the compressed vein or surgical decompression 1.
• The decision to treat varicocele should consider the presence of abnormal semen parameters, minimal/no identified female factor, and the couple's overall fertility goals, as suggested by the Practice Committee of the ASRM; Society for Male Reproduction and Urology (2014) 1.

Follow-up Care

• Follow-up appointments are typically scheduled 2-4 weeks after treatment to assess healing and improvement.
• Most patients experience significant improvement in pain symptoms within weeks of treatment, though fertility improvements may take 3-6 months to become apparent.
• Contact your doctor immediately if you experience severe pain, swelling, fever, or signs of infection after any procedure.

From the Research

Treatment of Varicocele

• Varicoceles are an abnormal dilation of the pampiniform plexus of veins within the scrotum, which can result in deleterious effects on male reproduction 2.
• Numerous therapeutic options are available for correcting varicoceles, including surgical varicocelectomy and radiographic venous embolization 2, 3.
• Varicocele correction is a more cost-effective therapeutic modality than both intrauterine insemination (IUI) and in vitro fertilization (IVF) for affected couples 2.

Next Steps in Management

• The main clinical indication for varicocele repair is testicular atrophy, and the mainstay of treatment for varicocele is surgical correction 4.
• In adult men, varicoceles are frequently present and surgically correctable, yet the measurable benefits of surgical repair are slight according to a Cochrane review 4.
• Scrotal ultrasonography has become the modality of choice in the diagnosis and post-treatment follow-up of varicocele, and interventional therapy is a minimally invasive effective treatment option for primary and salvage varicocele repair 5.

Compression of Gonadal Vein in Abdomen

• Varicocele is defined as a state of varicosity and tortuosity of the pampiniform plexus around the testis caused by retrograde blood flow through the internal spermatic vein 6.
• The pathophysiology of varicocele in testicular dysfunction remains unclear, but numerous studies have established significant improvement in the seminal parameters and pregnancy rates after varicocele repair 5, 6.
• Varicocele repair seems to represent a cost-effective therapeutic option for all males with a clinical varicocele in the presence of testicular hypotrophy, worsening sperm alterations or infertility 6.