From the Guidelines
For a patient with a testicular sonogram showing mild to moderate varicocele and mild hydrocele, the next steps typically involve a urological consultation for further evaluation, with a focus on monitoring and potential treatment if symptoms or fertility concerns arise, as recommended by the most recent guidelines 1. The patient's varicocele and hydrocele are currently mild, and most cases may only require observation without immediate intervention. The urologist will assess if the varicocele is causing symptoms like pain or discomfort, or if there are concerns about fertility, as varicoceles can affect sperm production and quality, according to the updates to male infertility guidelines 1.
- Key considerations include:
- Monitoring for changes in symptoms or testicular size
- Potential treatment options for symptomatic varicoceles, such as varicocelectomy or embolization
- Observation for mild hydroceles, which often resolve spontaneously
- Patient education on reporting any increase in pain, swelling, or changes in the testicle
- Use of over-the-counter pain relievers like ibuprofen (400-600mg every 6-8 hours) to manage discomfort, as needed
- Wearing supportive underwear to reduce pressure on the scrotum, if necessary It is essential to note that the routine use of ultrasonography to investigate presumed varicocele is discouraged, especially for non-palpable varicoceles, as treatment of these varicoceles is not associated with improvement in either semen parameters or fertility rates, as stated in the guidelines 1.
- The specific treatment approach will depend on the individual's symptoms, fertility goals, and the progression of the conditions over time, taking into account the latest recommendations from the American Urological Association and the American Society for Reproductive Medicine 1.
From the Research
Testicular Sonogram Findings
- The testicular sonogram revealed homogeneous normal size testicles bilaterally, with adequate systolic blood flow to both testicles.
- Mild to moderate left varicocele and mild left hydrocele were detected.
- No evidence of testicular torsion, mass, abscess, cyst, or epididymo-orchitis was found.
Varicocele Diagnosis and Treatment
- Varicoceles are relatively common, particularly in asymptomatic men, and are even more prevalent in subfertile men, representing the most common potentially correctable cause of male infertility 2.
- Ultrasound is the imaging modality of choice for varicocele evaluation, but there is no widely accepted consensus on examination technique, diagnostic criteria, or classification 2.
- The European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) has produced evidence-based recommendations for varicocele US examination, interpretation, and classification by consensus agreement 2.
- A semen analysis should be obtained for any male patient of reproductive age considering intervention for varicocele 3.
- Microsurgical subinguinal varicocele repair is considered the current surgical standard for varicocele treatment 3.
Hydrocele Formation
- Hydrocele is a known complication of varicocelectomy, with a reported incidence of 22.8% in one study 4.
- The incidence of hydrocele after laparoscopic varicocelectomy may be underreported, and the standard technique of laparoscopic varicocelectomy requires reexamination to potentially decrease hydrocele formation 4.
- Ligation and division of the spermatic vessels may increase the risk of hydrocele formation compared to ligation alone 4.
Treatment Options
- Microsurgical varicocelectomy remains the gold standard treatment option for infertile men with a clinically palpable varicocele and abnormal semen parameters 5.
- Newer evidence suggests a potential role for antioxidant supplementation and a meaningful role of varicocelectomy for patients destined for assisted reproductive technology (ART) to improve pregnancy outcomes 5.