Is a left varicocele worrisome?

Is a Left Varicocele Worrisome?

A left varicocele is generally not worrisome in most men, but becomes clinically significant when associated with infertility (abnormal semen parameters), testicular pain, testicular size asymmetry >2 mL, or when presenting with atypical features like hematuria that may indicate secondary causes. 1, 2

Understanding the Clinical Context

Left varicoceles are extremely common, affecting approximately 15% of the general male population, but this prevalence increases dramatically to 35-40% among men presenting with infertility. 1, 2 The left-sided predominance occurs due to anatomical factors including the longer left spermatic vein and its right-angle insertion into the left renal vein. 3

When a Left Varicocele Becomes Worrisome

Fertility-Related Concerns

• Grade 3 (large) varicoceles carry higher risk for testicular dysfunction and worse semen parameters compared to smaller grades. 1
• Men with varicoceles and abnormal semen parameters should be treated, as varicocele is present in 25% of men with abnormal semen analysis and represents the most common correctable cause of male infertility. 1, 4
• In severe cases, grade 3 varicoceles can progress to azoospermia, though varicocelectomy may restore sperm presence in ejaculate, particularly in men with hypospermatogenesis. 1

Testicular Size Asymmetry

• Persistent testicular size difference >2 mL or 20% confirmed on two visits 6 months apart warrants surgical intervention, particularly in adolescents where progressive testicular damage can occur. 1
• Varicoceles are progressive lesions that may hinder testicular growth and function over time. 4, 5

Pain Symptoms

• Chronic orchialgia from varicoceles responds well to treatment, with 87% of patients achieving complete pain relief at 39 months after gonadal vein embolization. 6

Red Flags Requiring Further Investigation

Atypical Presentations Suggesting Secondary Causes

• New-onset, large, or non-reducible varicoceles require abdominal imaging to exclude secondary causes such as renal masses or venous obstruction. 2
• Hematuria accompanying a varicocele should prompt evaluation for Nutcracker Syndrome (left renal vein compression), which can cause secondary varicocele. 7
• Right-sided or bilateral varicoceles, especially if the right side is large, warrant imaging to exclude retroperitoneal pathology. 2

When a Left Varicocele is NOT Worrisome

Subclinical (Non-Palpable) Varicoceles

• Routine ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of subclinical varicoceles does not improve fertility rates or semen parameters. 1, 2
• Ultrasound should only be used when physical examination is limited (obese patients, contracted dartos muscle). 2

Normal Semen Parameters

• Men with clinical varicoceles but normal semen analysis do not require treatment regardless of varicocele size or grade. 1

Clinical Decision Algorithm

For asymptomatic men with normal fertility:

• No intervention needed; varicocele is an incidental finding. 2

For men with infertility concerns:

• Obtain semen analysis
• If abnormal: treat clinical (palpable) varicoceles 1, 2
• If sperm count <5 million/mL: obtain karyotype and Y-chromosome microdeletion testing before surgery 1
• Expect 3-6 months for semen parameter improvement post-treatment 1, 2

For adolescents:

• Monitor testicular size every 6 months
• Treat if size asymmetry >2 mL persists or symptoms develop 1

For atypical presentations:

• Large, non-reducible, or new-onset: obtain abdominal/pelvic imaging 2
• Associated hematuria: evaluate for Nutcracker Syndrome 7

Important Caveats

Physical examination remains the gold standard for diagnosis and grading—imaging should not replace clinical assessment. 2 The pathophysiology involves multiple mechanisms including elevated scrotal temperature, testicular hypoxia, and reflux of toxic metabolites, which explains the progressive nature of testicular damage. 1, 5