What is the initial workup and management for a patient presenting with a scrotal mass diagnosed as a varicocele (varicose vein in the scrotum)?

Initial Workup and Management of Varicocele

Scrotal ultrasound with Doppler should be the initial diagnostic imaging for a patient presenting with a scrotal mass diagnosed as a varicocele, followed by semen analysis if the patient has fertility concerns. 1, 2

Diagnostic Evaluation

Clinical Assessment

• Physical examination should be performed in both supine and standing positions with Valsalva maneuver to properly assess the varicocele 3
• Only clinical (palpable) varicoceles typically require treatment 3
• Varicoceles are graded as:
  • Grade 1: Palpable only during Valsalva maneuver
  • Grade 2: Palpable without Valsalva
  • Grade 3: Visible through scrotal skin

Imaging

• Scrotal ultrasound with Doppler is the gold standard for confirmation 1, 2
• Diagnostic criteria on ultrasound:
  • Dilated, tortuous pelvic veins >4 mm
  • Slow or reversed blood flow
  • Multiple veins >2-3 mm in diameter 4
• MRI should NOT be used as initial evaluation for testicular lesions 1
• CT is not routinely indicated for varicocele evaluation 1

Laboratory Testing

• If fertility is a concern:
  • Semen analysis (at least two samples, one month apart) 2
  • Hormonal evaluation including testosterone, FSH, and LH 2
• Serum tumor markers (AFP, hCG, LDH) should be drawn if there's any suspicion of testicular malignancy 1

Management Algorithm

Indications for Treatment

1. Fertility concerns:

   • Abnormal semen parameters with clinical varicocele 2
   • Couple infertility with female partner having satisfactory ovarian reserve 3

2. Pain/discomfort:

   • Symptomatic varicocele causing scrotal pain or discomfort 2, 3

3. Testicular growth concerns:

   • Adolescents with reduced testicular growth or ipsilateral decrease in testicular volume 3

Treatment Options

1. Surgical Approaches

• Microsurgical varicocelectomy (inguinal or subinguinal):
  • Gold standard with lowest recurrence and complication rates 2, 3
  • Improves semen parameters in 60-70% of cases 2
  • Should be considered first-line for grade 3 varicoceles with documented testicular size decrease 2

2. Interventional Radiology

• Percutaneous embolization:
  • Minimally invasive alternative to surgery 3
  • Highly effective for pain relief (87% complete relief at 39 months) 2
  • Good option for recurrence after surgery 2

3. Conservative Management

• For patients who decline intervention or have mild symptoms:
  • Avoidance of prolonged standing and straining
  • Regular exercise
  • Wearing non-restrictive clothing
  • Weight loss if applicable 2

Post-Treatment Follow-Up

• Repeat semen analysis at 3-6 months post-procedure 2, 3
• Ultrasound evaluation at 3-6 months to assess testicular size and confirm procedure success 2
• Expected improvement in semen parameters occurs after 3 months (1-2 spermatogenic cycles) 2, 3
• Spontaneous pregnancy typically occurs between 6-12 months after varicocelectomy 2

Special Considerations

• Consider sperm banking before intervention, especially with significant testicular volume loss 2
• In cases of severe oligospermia, IVF with ICSI may be considered alongside or instead of varicocele repair 2
• Rule out underlying causes such as Nutcracker Syndrome in atypical presentations, especially when hematuria is present 5

Pitfalls to Avoid

• Don't rely solely on physical examination for diagnosis; confirm with Doppler ultrasound
• Don't treat subclinical (non-palpable) varicoceles detected only on imaging unless there are compelling reasons 3
• Don't delay treatment in adolescents with testicular growth discrepancy
• Don't forget to evaluate both partners when infertility is the presenting concern 3
• Don't use MRI as initial evaluation for scrotal masses 1