How do I treat or refer a patient with a right varicocele and normal testicular examination?

Management of Right Varicocele with Normal Testicular Examination

This patient requires urgent referral to urology for evaluation of possible retroperitoneal pathology, as isolated right-sided varicoceles are atypical and may indicate venous obstruction from an underlying mass. 1

Critical Red Flag Assessment

Right-sided varicoceles are pathologic until proven otherwise. The typical pattern is left-sided varicocele (due to the left spermatic vein's perpendicular insertion into the left renal vein), making right-sided varicoceles highly suspicious for secondary causes 1:

• Obtain abdominal/pelvic CT or MRI immediately to exclude retroperitoneal masses, renal tumors, or venous obstruction 1
• Right-sided varicoceles can result from compression or thrombosis of the inferior vena cava or right renal vein 1
• This is particularly urgent if the varicocele is large, non-reducible when supine, or of new onset 1

Evaluation Algorithm After Excluding Secondary Causes

If imaging rules out retroperitoneal pathology, proceed with the following assessment:

1. Fertility Status Evaluation

• Obtain semen analysis if the patient has fertility concerns or is planning paternity 2, 1
• Check FSH and testosterone levels if semen parameters are abnormal 3
• Evaluate female partner's ovarian reserve if applicable, as this influences treatment urgency 3, 1

2. Symptom Assessment

• Ask specifically about scrotal pain, heaviness, or discomfort 1
• Chronic orchialgia from varicoceles responds well to treatment, with 87% achieving complete pain relief after intervention 1

3. Testicular Size Measurement

• Measure both testes with ultrasound or orchidometer 2, 1
• A persistent size difference >2 mL or >20% confirmed on two visits 6 months apart is an indication for treatment, particularly in adolescents 3, 1

Treatment Indications

Treat the varicocele if ANY of the following are present 2, 1:

• Abnormal semen parameters in the context of couple infertility with adequate female ovarian reserve 2, 4
• Testicular size asymmetry >2 mL or >20% persisting over 6 months 3, 1
• Symptomatic varicocele causing chronic scrotal pain 1
• Adolescent patients with reduced testicular growth or volume decrease 4

Do NOT treat if 3, 2:

• Asymptomatic with normal fertility and no testicular size difference 1
• Subclinical (non-palpable) varicocele found only on ultrasound 3, 2
• Normal semen parameters in men not seeking fertility 3

Treatment Options

Microsurgical Varicocelectomy (Preferred)

• Microsurgical inguinal or subinguinal approach is the gold standard, offering lower recurrence and complication rates compared to high ligation or laparoscopic approaches 4
• Results in improvement in semen parameters and fertility rates 2, 4
• Expect improvement after 3-9 months (1-2 spermatogenic cycles) 3, 4

Percutaneous Embolization (Alternative)

• Minimally invasive option with satisfactory outcomes and rare complications 4, 5
• Particularly useful for recurrent varicoceles after surgical ligation 6
• 87% complete pain relief at 39 months for symptomatic patients 1

Important Caveats

• Genetic testing is mandatory if proceeding to treatment in men with sperm concentration <5 million/mL: obtain karyotype and Y-chromosome microdeletion analysis (AZFa, AZFb, AZFc) before surgery 3
• Do not routinely use ultrasound to hunt for subclinical varicoceles, as treating non-palpable varicoceles does not improve outcomes 3, 2
• Consider female partner factors before treatment decisions, especially if she has limited ovarian reserve, as waiting for sperm recovery may not be optimal 3
• Monitor post-treatment: repeat semen analysis at 3 and 6 months after varicocelectomy 3