Is a left scrotal varicocele (varicocele) with a resting maximum vessel diameter of 2.5 mm that increases to 3.1 mm on Valsalva (Valsalva maneuver) an indication for varicocelectomy (varicocelectomy)?

From the Guidelines

Varicocelectomy is not indicated for a left scrotal varicocele with a vessel diameter of 2.5 mm at rest that increases to 3.1 mm with Valsalva maneuver in the absence of symptoms, fertility issues, or testicular growth problems. According to the updates to male infertility: aua/asrm guideline (2024) 1, treatment of non-palpable varicoceles is not associated with improvement in either semen parameters or fertility rates.

Key Considerations

• The varicocele in question would be classified as grade 1-2 (mild to moderate) based on the vessel diameter measurements.
• Many urologists would recommend conservative management with regular monitoring rather than immediate surgical intervention for varicoceles of this severity.
• Scrotal ultrasound can be used to confirm the presence of varicocele and to determine procedural success after correction, but it is not necessary for initial evaluation in the absence of symptoms or fertility issues 1.

Clinical Decision-Making

• The decision for varicocelectomy should be individualized based on the patient's complete clinical picture, including symptoms, fertility goals, and any testicular size discrepancy.
• If the patient is experiencing pain, has documented fertility issues, or evidence of testicular atrophy, then varicocelectomy might be considered.
• The procedure involves ligating the dilated veins, which can be done through various approaches including microsurgical, laparoscopic, or open surgery, with a typical recovery time of 1-2 weeks.

Important Factors to Consider

• The presence of symptoms such as pain or discomfort
• Fertility issues or goals
• Testicular size discrepancy or atrophy
• The patient's overall clinical picture and medical history

From the Research

Indications for Varicocelectomy

The decision to perform varicocelectomy is based on various factors, including the presence of scrotal pain, varicocele grade, and semen parameters.

• Varicocelectomy is often recommended for patients with palpable varicoceles and abnormal semen parameters 2.
• The procedure is also indicated for patients with scrotal pain, testicular hypotrophy, and poor sperm DNA quality 2.
• A study published in 2005 found that varicocelectomy was effective in relieving scrotal pain in patients with left-sided varicocele, with 61.1% of patients reporting complete resolution of pain and 22.3% reporting partial resolution 3.

Varicocele Grade and Treatment Outcome

The grade of varicocele is an important factor in determining the outcome of varicocelectomy.

• A study published in 2023 found that patients with lower-grade varicoceles (Grade I and II) were more likely to experience complete resolution of pain after varicocelectomy, with 100% and 85.7% of patients experiencing complete resolution, respectively 4.
• Another study published in 2014 found that patients with higher-grade varicoceles (Grade 3) were more likely to experience significant improvement in symptoms after laparoscopic varicocelectomy, with 87.5% of patients experiencing significant improvement 5.

Vessel Diameter and Varicocelectomy

The maximum vessel diameter of 2.5 mm on rest and 3.1 mm on Valsalva is not explicitly mentioned in the provided studies as an indication for varicocelectomy.

• However, varicocelectomy is often recommended for patients with clinically significant varicoceles, which are typically defined as those that are palpable and have a diameter of 3 mm or greater 2.
• The decision to perform varicocelectomy should be based on a comprehensive evaluation of the patient's symptoms, physical examination, and diagnostic imaging results, rather than solely on vessel diameter 3, 2, 4, 5.