From the Guidelines
Treatment guidelines for varicoceles depend on symptoms and fertility concerns, with surgical repair being the standard approach for symptomatic cases or those with fertility issues, and percutaneous embolization as a non-surgical alternative. For asymptomatic varicoceles without fertility issues, observation is typically recommended with regular follow-up exams 1. When treatment is indicated due to pain, testicular atrophy, or infertility, the primary surgical options include open surgical repair (inguinal or subinguinal varicocelectomy), laparoscopic varicocelectomy, or microsurgical varicocelectomy, with the microsurgical approach generally preferred due to lower recurrence rates and fewer complications. Some key points to consider in the treatment of varicoceles include:
- Pain management before surgical intervention may include non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-600mg three times daily) or naproxen (250-500mg twice daily), scrotal support, and avoiding prolonged standing.
- Treatment is particularly important for adolescents with varicoceles causing testicular growth discrepancy to prevent potential fertility issues.
- Post-procedure, patients typically require 1-2 days of rest, with full recovery in 1-2 weeks.
- Improvement in semen parameters may take 3-6 months following successful repair, and patients should be monitored for potential complications such as hydrocele formation, testicular artery damage, or recurrence 1. It's worth noting that the provided evidence on varicose veins 1 is not directly applicable to varicoceles, and therefore, the treatment guidelines for varicoceles should be based on the relevant evidence 1.
From the Research
Treatment Options for Varicocele
- Varicocelectomy is the most commonly performed surgical procedure for the treatment of male infertility, with microsurgical varicocelectomy being the gold-standard approach due to high success rates and minimal complications 2.
- Percutaneous embolization of the internal spermatic vein is another option, offering a rapid recovery and a success rate of approximately 90% 3.
- Laparoscopy is also a treatment option for varicocele, although it is not as commonly used as varicocelectomy or percutaneous embolization.
Indications for Treatment
- Standard indications for varicocelectomy include palpable varicocele(s), with one or more abnormal semen parameters, and, for the couple trying to conceive, in the setting of normal or correctable female infertility 2.
- Varicocele repair is often recommended and undertaken for reasons other than infertility, including low serum testosterone, testicular pain, testicular hypotrophy, and poor sperm DNA quality 2.
- Percutaneous embolization is considered a viable option for men with unilateral left-sided varicoceles, as it offers similar failure rates to microsurgical varicocelectomy, but with some advantages to the patient 4.
Technical Considerations
- Microsurgical varicocelectomy is typically performed through a subinguinal or inguinal incision, and has a technical failure rate of less than 5% 2, 4.
- Percutaneous embolization requires interventional radiologic expertise and has potential serious complications, including vascular perforation, coil migration, and thrombosis of pampiniform plexus 3.
- Patient selection, preprocedure workup, and technical considerations are crucial for successful varicocele embolization, and the procedure should only be performed by experienced interventional radiologists 5.