Is a 6mm varicocele significant regardless of its grade?

Significance of a 6mm Varicocele Regardless of Grade

A 6mm varicocele is clinically significant regardless of its grade, as varicocele size correlates with testicular dysfunction and fertility outcomes. 1, 2

Varicocele Size and Clinical Significance

• Varicocele is present in approximately 15% of the normal male population, but this percentage increases to 25% in men with abnormal semen analysis and 35-40% in men presenting with infertility, demonstrating a clear correlation between varicocele and fertility issues 1, 2
• Higher varicocele grade (grade 3) is associated with worse semen parameters and greater testicular dysfunction 1
• The pathophysiology involves multiple mechanisms affecting testicular function, including higher scrotal temperature, testicular hypoxia, reflux of toxic metabolites, and increased DNA damage 1, 2

Size vs. Grade Considerations

• While grading (1-3) is based on physical examination findings, the actual venous diameter (measured in mm) provides additional objective information about varicocele severity 3
• A 6mm varicocele is typically considered substantial in size and likely corresponds to a higher-grade varicocele on physical examination 3
• Men with larger varicoceles (grade 3) have been shown to have lower preoperative sperm counts and poorer fertility indexes compared to men with grades 1 and 2 varicoceles 4

Impact on Fertility and Treatment Outcomes

• Infertile men with large varicoceles show greater improvement in semen parameters after varicocelectomy compared to those with smaller varicoceles 4
• Studies have shown that sperm concentration improved significantly in men with grade 2 varicoceles (from 33±5 million/cc to 41±6 million/cc) and even more dramatically in grade 3 varicoceles (from 18±5 million/cc to 32±7 million/cc) after microsurgical repair 4
• The fertility index (sperm count times percent motility) showed greater improvement in men with grade 3 varicoceles (128% improvement) compared to men with grade 1 (27%) or grade 2 (21%) varicoceles 4

Clinical Implications for Evaluation and Management

• The European Association of Urology strongly recommends surgery for varicocele when associated with a persistent small testis (size difference >2 mL or 20%), confirmed on two subsequent visits 6 months apart 1
• Treatment should be targeted to men with clinical varicoceles and abnormal semen parameters, as treatment of men with normal semen analysis or subclinical varicoceles is not recommended 2, 5
• Color Doppler ultrasonography is indicated in cases when the physical examination is indeterminate, but routine use to identify non-palpable varicoceles is discouraged 3

Important Considerations and Caveats

• Even in fertile men, grade 3 varicoceles are associated with higher seminal reactive oxygen species levels compared to lower grade varicoceles, suggesting potential for future fertility issues 6
• A study of fertile men found that as varicocele grade increased, seminal reactive oxygen species increased and sperm concentration decreased, indicating that grade 3 varicoceles may represent a different clinical entity even in fertile men 6
• Left-sided grade 3 varicoceles may affect not only testicular function but also epididymal function, as evidenced by improvements in alpha-glucosidase levels and decreased sperm droplets after varicocele repair 7
• After varicocele repair, improvements in semen parameters typically take up to two spermatogenic cycles (approximately 3-6 months) 2