From the Guidelines
The recommended management for a painful left-sided varicocele is endovascular therapy embolizing the affected spermatic vein using coils or sclerosants, as it has been shown to be effective in relieving orchialgia, with 87% of patients having complete pain relief at 39 months. This approach is supported by a study published in the American Family Physician in 2019 1. The management of a painful left-sided varicocele typically involves a multidisciplinary approach, considering both conservative and surgical options.
Conservative Management
Before considering surgical intervention, patients can try:
- Scrotal support (athletic supporter or specialized underwear)
- Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen for pain relief
- Activity modification to avoid heavy lifting or prolonged standing that may exacerbate symptoms
- Cold compresses for temporary relief
Surgical Options
If conservative management fails after 4-6 weeks, surgical options should be considered. The choice of surgical approach depends on surgeon expertise, patient preference, and specific clinical factors. Alternative procedures include microsurgical varicocelectomy and laparoscopic varicocelectomy. However, endovascular therapy embolization is a preferred option due to its effectiveness in relieving pain. A recent guideline update on male infertility published in The Journal of Urology in 2024 1 emphasizes the importance of correcting palpable varicoceles to improve semen quality and fertility, but it does not directly address the management of painful varicoceles.
Key Considerations
- Pain improvement occurs in approximately 70-90% of patients following surgical intervention, though complete resolution may take several months
- The underlying mechanism of pain relief involves eliminating venous reflux and reducing testicular congestion, which addresses the root cause of discomfort rather than just masking symptoms
- Scrotal ultrasound can be used before repair to confirm the presence of varicocele and also following correction to determine procedural success, in the context of shared decision-making with the patient.
From the Research
Management Options for Left-Sided Varicocele Causing Pain
The recommended management for a left-sided varicocele causing pain includes several options, which are discussed below:
- Surgical Management: Robotic gonadal vein excision has been reported to be effective in treating chronic abdominal pain after varicocele embolization 2. This approach may be considered for patients who have failed conservative measures.
- Embolization: Varicocele embolization is a minimally invasive technique that can be used to treat varicoceles, especially in patients who have experienced recurrence after surgical treatment 3. This approach has several advantages, including the use of local anesthesia, lower operating time, and faster recovery times.
- Shunt Operation: A shunt operation, which involves anastomosis of the proximal part of the spermatic vein and inferior epigastric vein, has been reported to be effective in managing nutcracker phenomenon presenting as left varicocele in adolescents 4.
- Endovenous Stenting: Iliac vein stenting has been reported to be effective in treating left-sided varicocele caused by May-Thurner syndrome 5.
- Percutaneous Embolization: Percutaneous embolization of the internal spermatic vein is a minimally invasive technique that can be used to treat varicoceles 6. This approach has a high success rate and can be performed under local anesthesia.
Considerations for Management
When considering management options for left-sided varicocele causing pain, it is essential to evaluate the individual patient's condition and medical history. The choice of management option will depend on various factors, including the severity of symptoms, the presence of any underlying conditions, and the patient's overall health status. In some cases, a combination of management options may be necessary to achieve optimal results.