Do patients with varicocele need to be referred?

From the Guidelines

Patients with varicocele should be referred to a urologist if they have pain, testicular atrophy, abnormal semen parameters, or infertility concerns, as indicated by the most recent guidelines from the American Urological Association and the American Society for Reproductive Medicine 1. The decision to refer a patient with varicocele depends on various factors, including the presence of symptoms, semen quality, and fertility status.

• The 2024 guidelines from the American Urological Association and the American Society for Reproductive Medicine suggest that treatment of varicocele may improve semen quality and fertility in selected patients 1.
• According to the World Health Organization reference limits for human semen characteristics, abnormal semen parameters include low semen volume, total sperm number, sperm concentration, vitality, progressive motility, and total motility 1.
• The guidelines also recommend that scrotal ultrasound can be used to confirm the presence of varicocele and to determine procedural success after correction, but it should not be used as a routine diagnostic tool for non-palpable varicoceles 1.
• In contrast, the 2017 report from the Practice Committee of the ASRM and the Society for Male Reproduction and Urology suggests that treatment of a clinically palpable varicocele may be offered to the male partner of an infertile couple when there is evidence of abnormal semen parameters and minimal/no identified female factor 1.
• However, the most recent and highest-quality study, which is the 2024 guideline, should be prioritized when making a definitive recommendation 1.
• Therefore, referral to a urologist is recommended for patients with varicocele who have symptoms or potential fertility issues, and treatment options may include surgical repair or interventional radiologic procedures.
• Primary care providers should monitor asymptomatic varicoceles annually with physical examination to assess for development of symptoms or testicular size changes that would warrant referral.

From the Research

Referral Criteria for Patients with Varicocele

• Patients with varicocele do not always require referral to a specialist, as most cases can be diagnosed and managed through clinical examination alone 2.
• However, certain conditions may necessitate referral, such as:
  • Suspected intra-abdominal malignancy, particularly if the patient is over 40 and the varicocele does not disappear on lying down 2.
  • Significant pain or discomfort associated with the varicocele 2.
  • Fertility problems, in which case the patient should be referred to a urologist with a specialist interest in fertility and an expert in assisted reproduction techniques 2.
• The decision to refer a patient with varicocele should be based on a thorough history and examination, including an assessment of the patient's symptoms, medical history, and fertility status 2, 3, 4.

Special Considerations for Adolescent Patients

• Adolescent patients with varicocele may require different management approaches, as the condition can affect testicular growth and development 3, 5.
• Current recommendations suggest that adolescents with varicocele and impaired testicular growth or spermatogenesis may benefit from early evaluation and selective treatment 3.
• However, the majority of men with varicocele will be fertile, and not all cases require surgical treatment 3, 6.

Evaluation and Treatment Options

• A semen analysis should be obtained for any male patient of reproductive age considering intervention for varicocele 5.
• Treatment options for varicocele include surgery or percutaneous embolization, which should be performed by a well-trained and experienced operator 4.
• The treatment of varicocele can be considered a first-line treatment in patients with moderate oligo-astheno-teratospermia and no associated female infertility factor 4.