What are the symptoms and treatment options for testicular varicocele?

Testicular Varicocele: Symptoms and Treatment

Treatment of a clinically palpable varicocele should be offered to men with abnormal semen parameters and minimal/no identified female factor infertility to improve fertility outcomes. 1, 2

Symptoms of Varicocele

• Testicular pain associated with varicocele is typically described as a dull, aching, or throbbing pain in the testicle, scrotum, or groin; rarely, it can be acute, sharp, or stabbing 3
• Many varicoceles are asymptomatic and are discovered during routine physical examination 4
• Varicoceles may cause testicular atrophy with impaired sperm production and decreased Leydig cell function in some males 4
• The presence of a prominent pampiniform plexus (dilated veins) is diagnostic of varicocele 2
• Higher grade varicoceles (grade 3) are associated with worse semen parameters and greater testicular dysfunction 5

Diagnosis

• Physical examination is the primary method of diagnosis, with a prominent pampiniform plexus being diagnostic of varicocele 2
• Scrotal Doppler ultrasound should be performed to confirm the grade of varicocele, evaluate blood flow patterns, and is particularly useful in patients where physical examination is difficult (e.g., obese patients) 2
• Routine use of ultrasonography to identify non-palpable (subclinical) varicoceles is discouraged as treatment of these varicoceles is not associated with improvement in semen parameters or fertility rates 2, 6

Treatment Options

Indications for Treatment

• 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 6
• The European Urology guideline recommends treating varicocele in infertile men with clinical varicocele, abnormal semen parameters, and otherwise unexplained infertility, especially when the female partner has good ovarian reserve 2
• Treatment is also recommended for adolescents with varicocele associated with a persistent small testis (size difference >2 ml or 20%), confirmed on two subsequent visits 6 months apart 2

Surgical Options

• Microsurgical varicocelectomy is the gold standard for treatment in adults, with minimal complication rates and favorable outcomes 3
• Laparoscopic approaches are more commonly used for adolescent varicoceles 7
• Varicocelectomy resolves testicular pain in approximately 80% of carefully selected candidates with clinically palpable varicocele 3

Non-Surgical Options

• Management of testicular pain associated with varicocele should start with a conservative, non-surgical approach and a period of observation 3
• Percutaneous embolization is an alternative to surgical correction with similar efficacy in improving semen parameters 8

Treatment Outcomes

• After varicocele repair, improvements in semen parameters typically take up to two spermatogenic cycles (approximately 3-6 months), with spontaneous pregnancy occurring between 6 and 12 months after varicocelectomy 6
• Varicocele repair has been shown to improve semen parameters and fertility outcomes in men with clinical varicoceles and abnormal semen analysis 6
• Severe varicoceles show greater improvement in sperm count after surgical repair compared to moderate or mild varicoceles 6
• Varicocelectomy may also improve outcomes in men undergoing assisted reproductive technologies 6
• In cases of azoospermia, varicocelectomy may lead to the presence of sperm in the ejaculate, especially for those with a histological diagnosis of hypospermatogenesis 5

Important Considerations and Caveats

• Varicoceles are present in approximately 15% of the normal male population but 35-40% of men presenting with infertility, indicating a significant association between varicocele and fertility problems 6, 5
• Only 20% of men with a documented varicocele will suffer from fertility problems 4
• The pathophysiology of varicocele involves multiple mechanisms affecting testicular function, including higher scrotal temperature, testicular hypoxia, reflux of toxic metabolites, and increased DNA damage 5, 6
• The quality of evidence regarding varicocele treatment in azoospermia is generally low 5
• Special consideration should be given to couples with a female partner with limited ovarian reserve, as time spent waiting for sperm recovery may impact overall fertility outcomes 5