From the Guidelines
Varicoceles are a common condition that can affect fertility and cause discomfort, with risk factors including being an adolescent or young adult male, having a family history of varicoceles, and left-sided predominance due to anatomical factors like the left spermatic vein's perpendicular entry into the renal vein. The management of varicoceles depends on symptoms and fertility concerns. According to the most recent guidelines, asymptomatic varicoceles without fertility issues should be managed with observation and regular monitoring 1.
Risk Factors
The risk factors for varicoceles include:
- Being an adolescent or young adult male
- Having a family history of varicoceles
- Left-sided predominance due to anatomical factors like the left spermatic vein's perpendicular entry into the renal vein
- Low semen volume (<1.4 mL) and acidic semen (pH <7.0) may indicate distal male genital tract obstruction, which can be associated with varicoceles 1
Management Options
Management options for varicoceles depend on symptoms and fertility concerns. For symptomatic varicoceles, supportive measures like scrotal support, anti-inflammatory medications (ibuprofen 400-600mg three times daily as needed), and avoiding prolonged standing can be used. Definitive treatment involves surgical correction through various approaches: microsurgical subinguinal varicocelectomy (preferred due to lower complication rates), laparoscopic varicocelectomy, or radiological embolization. Surgery is typically recommended for men with infertility and abnormal semen parameters, adolescents with testicular growth discrepancy, or those with persistent pain 1.
Diagnostic Evaluation
The diagnostic evaluation of varicoceles should include a physical exam and semen analysis. Scrotal ultrasound can be used to confirm the presence of varicocele and to determine procedural success after correction 1. However, routine use of ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of these varicoceles is not helpful 1. Transrectal ultrasonography (TRUS) or pelvic MRI may be recommended in males with semen analysis suggestive of ejaculatory duct obstruction (EDO) 1.
Post-Procedure Care
Post-procedure, patients should avoid heavy lifting for 1-2 weeks and may require short-term pain management. Improvement in semen parameters typically takes 3-6 months following successful treatment, reflecting the spermatogenesis cycle. Regular follow-up is essential to monitor for recurrence, which occurs in approximately 10-15% of cases depending on the surgical technique used.
From the Research
Risk Factors for Varicocele
- Varicocele is found in approximately 20% of adults and adolescents and in 19-41% of men seeking treatment for infertility 2
- The incidence of varicocele increases with age and has a higher incidence in infertile men 3
- Genetic and epigenetic changes, associated with the environment, might be involved in causing infertility and decrease in sperm quality in varicocele patients 2
- Chromosomal disorders, mutations, polymorphisms, changes in gene expression, and epigenetic changes have all been reported to be associated with varicocele 2
Management Options for Varicoceles
- Surgical repair either by open or microsurgical approach, laparoscopy, or through percutaneous embolization of the internal spermatic vein are available options for the treatment of varicocele 4
- Percutaneous embolization offers a rapid recovery and can be successfully accomplished in approximately 90% of attempts, but demands interventional radiologic expertise and has potential serious complications 4
- Varicocele correction is a more cost-effective therapeutic modality than both intrauterine insemination (IUI) and in vitro fertilization (IVF) for affected couples 5
- Percutaneous embolization offers nonsurgical, minimally invasive option for the treatment of varicoceles, requiring only minimal sedation 3
- Clinical practice guidelines from various international professional societies are available for varicocele treatment, including guidelines from the Korean Society for Sexual Medicine and Andrology 6