Treatment of Varicocele
The treatment of varicocele should be surgical varicocelectomy or radiographic venous embolization for men with abnormal semen parameters and clinical (palpable) varicocele, as these interventions significantly improve semen parameters and increase chances of spontaneous pregnancy. 1
Indications for Treatment
Treatment is indicated in the following scenarios:
- Men with abnormal semen parameters and clinical varicocele
- Men with non-obstructive azoospermia and clinical varicocele (may improve sperm retrieval rates)
- Patients with palpable (grade 3) varicocele with documented decrease in testicular size
- Patients with chronic scrotal pain related to varicocele
Treatment is generally NOT indicated for:
- Subclinical varicocele (non-palpable, detected only by imaging)
- Men with normal semen parameters
Diagnostic Evaluation Before Treatment
- Physical examination to confirm palpable varicocele
- Scrotal ultrasound with Doppler - gold standard for confirmation
- Semen analysis - at least two samples, one month apart
- Hormonal evaluation - testosterone, FSH, and LH levels to assess testicular function
- Consider additional imaging (CT angiography) if secondary causes like Nutcracker Syndrome are suspected, especially with hematuria 2
Treatment Options
1. Surgical Approaches
Microsurgical varicocelectomy (subinguinal or inguinal) - considered optimal treatment in most cases 3
- Highest success rates
- Lowest recurrence rates
- Lower risk of hydrocele formation
Laparoscopic varicocelectomy - useful in specific cases
- Higher risk of complications
- Longer recovery time
2. Radiological Approaches
- Percutaneous embolization
- Highly effective for pain relief (87% complete pain relief at 39 months) 1
- Less invasive alternative to surgery
- Can be performed as outpatient procedure
3. Conservative Management
For patients who are not candidates for interventional procedures:
- Avoidance of prolonged standing and straining
- Regular exercise
- Wearing non-restrictive clothing
- Weight loss if applicable
Post-Treatment Follow-up
- Improvement in semen parameters typically occurs within 3 months (two spermatogenic cycles)
- Spontaneous pregnancy typically occurs between 6-12 months after treatment
- Repeat semen analysis is essential 3-6 months after varicocele repair
- Ultrasound evaluation to assess testicular size and confirm procedure success
Potential Complications
Some patients may experience persistent scrotal pain after varicocelectomy due to:
- Recurrence of varicocele
- Development of hydrocele
- Neuralgia
- Referred pain
- Ureteral lesions
- Nutcracker syndrome 4
Special Considerations
Adolescents: Most varicoceles in adolescents are detected during routine medical examinations. Treatment is typically recommended if testicular atrophy is present. Laparoscopic approach is more common in adolescents than in adults 5
Infertile men: If infertility persists 6 months after varicocele repair, other therapies including assisted reproductive technology should be considered, especially in older couples 3
Secondary varicoceles: Require careful evaluation to rule out underlying causes such as Nutcracker Syndrome. In mild cases, varicocelectomy alone can effectively relieve scrotal pain 2