What is the treatment for varicocele?

Varicocele Treatment Guidelines

Endovascular therapy (embolization) or microsurgical varicocelectomy is the standard treatment for varicoceles in cases of orchialgia, infertility, or reduced testicular size in adolescents. 1

Indications for Treatment

Treatment is indicated in the following scenarios:

• Symptomatic pain (orchialgia)
• Infertility without other apparent causes
• Reduced testicular size/testicular atrophy, especially in adolescents
• Documented valvular reflux in non-pregnant patients 1

Diagnostic Approach

Before treatment, proper diagnosis should be confirmed with:

• Physical examination (primary diagnostic method) 2
• Color Doppler ultrasound using three criteria:
  • Dilated, tortuous pelvic vein >4 mm
  • Slow/reversed blood flow
  • Dilated arcuate vein in myometrium 1
• Initial fertility evaluation including:
  • At least two semen analyses one month apart
  • Hormonal evaluation (testosterone, FSH, LH) to assess testicular function 1

Treatment Options

1. Surgical Options

• Microsurgical Varicocelectomy:

  • Recommended by the American Urological Association when varicocele is palpable (grade 3) with documented decrease in testicular size 1
  • Can improve semen parameters in 60-70% of cases 1
  • Preferred approach is inguinal, except with previous inguinal surgery history 2
  • Use of operating microscope and micro Doppler probe improves identification of vessels and lymphatics 2

• Laparoscopic Approach:

  • More commonly used in adolescents than adults 3
  • Alternative when other approaches are contraindicated

2. Interventional Radiology Options

• Endovascular Therapy (Embolization):

  • Highly effective for pain relief (87% complete pain relief at 39 months) 1
  • Minimally invasive, requiring only minimal sedation 4
  • More cost-effective than assisted reproductive techniques like IUI and IVF 5

• Sclerotherapy:

  • Used for small to medium veins or recurrent varicocele after surgery
  • Involves ultrasound-guided injection of sclerosing agents (hypertonic saline, sodium tetradecyl, polidocanol)
  • No evidence that any sclerosing agent is superior 1

Treatment Algorithm

1. For symptomatic varicocele with pain:

   • First-line: Endovascular embolization (highest pain relief success) 1
   • Alternative: Microsurgical varicocelectomy

2. For infertility with palpable varicocele:

   • First-line: Microsurgical varicocelectomy 1
   • Consider sperm banking before intervention 1
   • For severe oligospermia: Consider IVF with ICSI alongside or instead of repair 1

3. For adolescents with testicular size discrepancy:

   • First-line: Microsurgical varicocelectomy or laparoscopic approach 1, 3

4. For patients not candidates for surgery:

   • Endovenous thermal ablation 1
   • Conservative management (avoidance of prolonged standing/straining, regular exercise, non-restrictive clothing, weight loss if applicable) 1

Post-Treatment Evaluation

• Ultrasound evaluation 3-6 months after treatment to assess testicular size 1
• Repeat semen analysis 3-6 months after treatment to evaluate improvement 1

Clinical Caveats

• Despite being common in infertile men, only 20% of men with varicocele will experience fertility problems 3
• Benefits of surgical repair may be modest according to some reviews 3
• Difficult to predict which adolescents with varicocele will develop diminished testicular function 3
• No established direct link between varicocele and prostate cancer risk 1
• Treatment of subclinical varicoceles remains controversial with sparse supporting data 2

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