What is the treatment approach for varicocele (varicose veins in the scrotum)?

Treatment Approach for Varicocele

Endovenous thermal ablation is recommended as first-line treatment for symptomatic varicocele with documented valvular reflux in non-pregnant patients, and need not be delayed for a trial of external compression. 1

Diagnosis and Evaluation

Before initiating treatment, proper evaluation is essential:

• Perform semen analysis (at least two samples, one month apart) to assess fertility potential 2
• Consider hormonal evaluation including testosterone, FSH, and LH levels to assess testicular function 2
• Use color Doppler ultrasound when physical examination is difficult (e.g., in obese patients) 2
• Scrotal ultrasound can confirm varicocele presence before repair and determine procedural success afterward 2
• Routine ultrasound to identify non-palpable varicoceles is discouraged as they don't significantly improve fertility outcomes 2

Treatment Algorithm

1. Conservative Management

• Appropriate for:
  • Patients who are not candidates for interventional procedures
  • Patients who do not desire intervention
  • Pregnant women 1

Conservative measures include:

• Avoidance of prolonged standing and straining
• Regular exercise
• Wearing non-restrictive clothing
• Weight loss if applicable 1

2. Interventional Treatment Options

A. Endovenous Thermal Ablation

• First-line treatment for symptomatic varicocele with documented valvular reflux 1
• Procedure:
  • Under ultrasound guidance, a laser optical fiber or radiofrequency catheter is inserted into the vein
  • Heat coagulates blood in the vein, closing it and redirecting blood flow to functional veins
  • Performed under local anesthesia
  • Same-day discharge with quick return to normal activities 1
• Potential complication: Risk of surrounding nerve damage (approximately 7%), though most nerve damage is temporary 1

B. Endovenous Sclerotherapy

• Typically used for small to medium veins (1-5 mm) or recurrent varicocele after surgery 1
• Procedure:
  • Ultrasound-guided injection of sclerosing agent into the vein
  • Agents include hypertonic saline, sodium tetradecyl, and polidocanol
  • No evidence that any agent is superior to others 1

C. Microsurgical Varicocelectomy

• Can improve semen parameters in 60-70% of cases 2
• Specifically recommended when:
  • Varicocele is palpable (grade 3) with documented decrease in testicular size 2
  • To preserve fertility potential 2

D. Percutaneous Embolization

• Offers a non-surgical, minimally invasive option
• Requires only minimal sedation 3

3. Special Considerations

• IVF with ICSI may be considered alongside or instead of varicocele repair, especially in cases of severe oligospermia 2
• Sperm banking should be discussed before any intervention, especially with significant testicular volume loss 2
• Early treatment of grade 3 varicocele with testicular atrophy is best to prevent further decline in testicular function 2

Follow-up After Treatment

• Ultrasound evaluation 3-6 months after treatment to assess testicular size and confirm procedure success 2
• Repeat semen analysis 3-6 months after treatment to evaluate improvement 2

Important Caveats

• Complete recovery of lost testicular volume is unlikely even after successful treatment 2
• While varicoceles are present in approximately 15% of the general male population, only 20% of men with a documented varicocele will suffer from fertility problems 4
• The goals of treatment are the same in adolescent and adult patients, though the approach may differ (laparoscopic more common in adolescents) 4
• Varicocele correction is more cost-effective than both intrauterine insemination and in vitro fertilization for affected couples 5