What is the recommended treatment for a 21-year-old male with a left varicocele (varicose vein in the scrotum)?

Treatment Recommendation for Left Varicocele in a 21-Year-Old Male

The management of a left varicocele in a 21-year-old male depends critically on whether he has fertility concerns, abnormal semen parameters, or testicular size asymmetry—observation is appropriate if he has normal testicular volumes and no fertility issues, but surgical repair (preferably microsurgical varicocelectomy) is strongly recommended if he has abnormal semen analysis with infertility concerns or persistent testicular size difference >2 mL or 20%. 1

Initial Evaluation Required

Before making treatment decisions, the following assessment is essential:

• Physical examination findings: Confirm the varicocele is clinically palpable (not just detected on ultrasound), as only clinical varicoceles warrant treatment 1, 2
• Testicular volume assessment: Measure both testes to identify any size difference >2 mL or 20%, which should be confirmed on two visits 6 months apart 1, 3
• Fertility status and plans: Determine if the patient is currently trying to conceive or plans future paternity 4
• Semen analysis: If fertility is a concern, obtain baseline semen parameters to identify abnormalities 1, 2

Treatment Algorithm

DO NOT TREAT if:

• The varicocele is subclinical (non-palpable, only detected on ultrasound) 1, 2
• Semen analysis is completely normal AND testicular volumes are symmetric AND no fertility concerns exist 1
• The patient has no symptoms, normal testicular volumes, and no current or planned fertility needs 4

STRONGLY RECOMMEND TREATMENT if:

• Persistent testicular size asymmetry: Left testis is smaller by >2 mL or 20% compared to the right, confirmed on two separate examinations 6 months apart 1, 3
• Infertility with abnormal semen parameters: Clinical varicocele with documented sperm abnormalities in a man attempting conception (assuming female partner has adequate ovarian reserve) 1, 2
• Symptomatic varicocele: Pain or discomfort attributable to the varicocele 4

MAY CONSIDER TREATMENT in:

• Men with abnormal semen parameters even without active fertility plans, to preserve future reproductive potential 4
• Elevated sperm DNA fragmentation with unexplained infertility 1
• Recurrent pregnancy loss or failed assisted reproductive techniques 1

Surgical Approach

Microsurgical varicocelectomy (inguinal or subinguinal approach) is the gold standard, offering the lowest recurrence and complication rates compared to other techniques 4

• Alternative option: Percutaneous retrograde embolization is a minimally invasive alternative with satisfactory outcomes and rare complications 4
• Avoid: High surgical approaches (laparoscopic or open without magnification) have higher recurrence and complication rates 4

Expected Outcomes and Timeline

• Semen parameter improvements: Require 3-6 months (two spermatogenic cycles) to manifest 5, 3
• Testicular volume recovery: Follows similar timeline of 3-6 months 3
• Fertility benefits: Recent evidence confirms varicocelectomy increases natural pregnancy rates and is more cost-effective than IUI or IVF 6
• Earlier intervention: May prevent permanent testicular damage, particularly important in young men 3

Critical Pitfalls to Avoid

• Do not order ultrasound to hunt for subclinical varicoceles—routine ultrasonography to identify non-palpable varicoceles is discouraged, as treating them does not improve outcomes 2, 4
• Do not treat based on ultrasound findings alone—the diagnosis must be clinical (palpable on examination) 2, 4
• Do not delay evaluation if testicular asymmetry exists—progressive testicular damage can occur, and earlier intervention may prevent permanent dysfunction 3, 7
• Consider female partner evaluation—if fertility is the concern, ensure the female partner has adequate ovarian reserve before proceeding, as time to improvement matters 1, 5

Special Considerations for This Age Group

At 21 years old, this patient is at a critical juncture where varicocele may progressively impair testicular function over time 7. Even if he has no immediate fertility plans, testicular volume asymmetry is a strong indication for intervention to prevent future reproductive compromise 1, 3. The prevalence of varicocele in the general male population is 15%, but it affects 35-40% of infertile men, demonstrating its progressive impact on fertility 5, 2.