What is the treatment for varicocele?

Treatment of Varicocele

Surgical varicocelectomy is the recommended treatment for varicocele in men with abnormal semen parameters and clinical varicocele, as it significantly improves semen parameters and increases chances of spontaneous pregnancy. 1, 2

Diagnostic Evaluation

Before initiating treatment, proper evaluation is essential:

• Scrotal ultrasound with Doppler is the gold standard for confirmation of varicocele diagnosis 2
• Semen analysis (at least two samples, one month apart) to assess fertility potential 2
• Hormonal evaluation (testosterone, FSH, LH) to assess testicular function 2

Treatment Indications

Treatment is indicated in the following scenarios:

• Abnormal semen parameters with clinical (palpable) varicocele 1, 2
• Testicular atrophy/size discrepancy 2
• Symptomatic varicocele causing pain 2, 3

Treatment is generally NOT indicated for:

• Subclinical varicocele (non-palpable, detected only by imaging) 1
• Men with normal semen parameters 1, 2

Treatment Options

1. Surgical Varicocelectomy

• Microsurgical varicocelectomy (subinguinal or inguinal approach) is considered the optimal treatment in most cases 2, 4
  • Improves semen parameters in 60-70% of cases 2
  • Lower complication rates compared to other surgical approaches

2. Radiological Interventions

• Endovascular embolization
  • Highly effective for pain relief (87% complete pain relief at 39 months) 2
  • Good alternative for patients who want to avoid surgery
  • Higher recurrence rates than microsurgical approach

3. Other Surgical Approaches

• Laparoscopic varicocelectomy 4
• Retroperitoneal approach 5
• Ivanissevich technique (high ligation) 3

Expected Outcomes

• Improvement in semen parameters occurs within two spermatogenic cycles (approximately 3 months) 1, 2
• Spontaneous pregnancy typically occurs between 6-12 months after varicocelectomy 1, 2
• Varicocelectomy may lead to the presence of sperm in ejaculate for men with azoospermia 1, 2

Follow-up

• Repeat semen analysis 3-6 months after repair to assess improvement 2
• Ultrasound evaluation 3-6 months after treatment to confirm procedure success 2

Special Considerations

• In cases of non-obstructive azoospermia with clinical varicocele, varicocelectomy may improve surgical sperm retrieval rates, especially in patients with hypospermatogenesis 1, 2
• Consider IVF with ICSI alongside or instead of varicocele repair in cases of severe oligospermia 2
• Secondary varicoceles may be caused by underlying conditions like Nutcracker Syndrome, which should be evaluated when hematuria is present 3
• Sperm banking should be considered before any intervention, especially if there is significant testicular volume loss 2

Conservative Measures

For patients who are not candidates for surgical intervention:

• Avoidance of prolonged standing and straining
• Regular exercise
• Wearing non-restrictive clothing
• Weight loss if applicable 2

Treatment of varicocele should be approached systematically, with microsurgical varicocelectomy being the preferred option for men with abnormal semen parameters and clinical varicocele. The decision to treat should be based on clinical findings, semen parameters, and patient symptoms.