What is the recommended treatment for marked varicoceles (enlarged veins in the scrotum) with sizes of up to 4.5mm on the right side and 6.3mm on the left side?

Management of Marked Bilateral Varicoceles with Left Testicular Hypotrophy

Given the marked bilateral varicoceles (6.3mm left, 4.5mm right) with documented left testicular hypotrophy, surgical varicocelectomy is indicated and should be performed, with microsurgical subinguinal approach being the preferred technique. 1

Key Clinical Findings Requiring Intervention

Your ultrasound demonstrates several concerning features that warrant treatment:

• Bilateral grade III varicoceles are present based on vein diameters of 6.3mm (left) and 4.5mm (right), as grade III varicoceles typically measure ≥6.6mm, grade II measures 5.8mm, and grade I measures 5.0mm 1
• Left testicular hypotrophy ("slightly smaller than the right testis") represents a critical indication for intervention, as the European Association of Urology strongly recommends surgery when varicocele is associated with testicular size difference >2 mL or 20% 2, 1
• The combination of bilateral varicoceles with testicular size discrepancy significantly increases the risk of progressive testicular dysfunction and potential fertility impairment 2

Treatment Recommendation

Microsurgical varicocelectomy is the optimal treatment approach for the following reasons:

• Microsurgical subinguinal varicocelectomy probably improves pregnancy rates (RR 1.18,95% CI 1.02 to 1.36) and reduces varicocele recurrence rates (RR 0.48,95% CI 0.29 to 0.79) compared to other surgical techniques 3
• This approach has a recurrence rate as low as 2.8% when performed with rigorous technique 4
• The procedure can be performed with same-day discharge and rapid return to activities 5

Alternative Treatment Options (Second-Line)

• Endovascular embolization is an alternative radiological approach that achieves 87% complete pain relief at 39 months for orchialgia 5
• However, surgical and radiological treatments show uncertain comparative effectiveness for live birth and pregnancy outcomes (RR 1.13,95% CI 0.75 to 1.70) 3

Important Clinical Considerations

Timing and Urgency

• Early intervention is recommended to prevent permanent testicular damage, particularly given the documented testicular size discrepancy 2
• The European Association of Urology recommends confirmation of persistent testicular hypotrophy on two subsequent visits 6 months apart before proceeding with surgery in adolescents, though this may not apply if you are an adult 2, 1

Expected Outcomes

• Semen parameter improvements typically require 3-6 months (two spermatogenic cycles) after varicocelectomy 2, 6
• Mean testicular volume may increase after surgery, though improvements are not always statistically significant 4
• Treatment may lead to presence of sperm in ejaculate for men with azoospermia, especially those with hypospermatogenesis 2

Potential Complications

• Hydrocele formation is the main postoperative concern, occurring in 4-13% of cases depending on whether tunica vaginalis is reversed or resected 4
• Nerve damage occurs in approximately 7% of cases with thermal ablation techniques, though most damage is temporary 5
• Other potential complications include hematoma, epididymitis, and wound infection, though rates are generally low 3

What NOT to Do

• Do not pursue treatment of subclinical (non-palpable) varicoceles detected only by ultrasound, as this is not effective at improving fertility outcomes 2, 1
• Do not delay treatment if fertility is a concern and the female partner has limited ovarian reserve, as time spent waiting may impact overall fertility outcomes 2
• Do not expect immediate results - allow at least 3-6 months for semen parameter improvement before considering the procedure unsuccessful 2, 6

Risk Stratification for Fertility Impact

• Varicoceles affect 15% of normal males but 35-40% of men presenting with infertility 1, 6
• Higher varicocele grades (grade III) are associated with worse semen parameters and greater testicular dysfunction 2, 1
• The presence of testicular hypotrophy significantly increases the likelihood of impaired spermatogenesis 2