What is the management of a small varicocele?

Management of Small Varicoceles

For small varicoceles, treatment is not indicated in asymptomatic men with normal fertility parameters, but intervention is warranted when specific high-risk features are present: abnormal semen analysis in infertile men, persistent testicular size asymmetry >2 mL or 20% in adolescents, or chronic testicular pain. 1, 2

Clinical Decision Algorithm

Asymptomatic Men with Normal Fertility

• No treatment is recommended for men with small varicoceles who have normal semen analysis or subclinical (non-palpable) varicoceles, regardless of grade 1, 2
• These represent incidental findings without clinical significance in the absence of fertility concerns or symptoms 2
• Routine ultrasonography to identify subclinical varicoceles should be avoided, as treating non-palpable varicoceles does not improve semen parameters or fertility rates 1, 3

Infertile Men with Small Varicoceles

• Obtain semen analysis first to determine if abnormal parameters are present 2
• Treat with varicocelectomy if the patient has a clinical (palpable) varicocele with abnormal semen parameters and otherwise unexplained infertility, particularly when the female partner has good ovarian reserve 1, 2
• The 2025 European Association of Urology guidelines provide strong evidence that treating clinical varicoceles in this population improves fertility rates 1
• Even small grade varicoceles warrant treatment when associated with abnormal semen analysis, as varicocele represents the most common correctable cause of male infertility, present in 25% of men with abnormal semen parameters 2

Adolescents with Small Varicoceles

• Monitor testicular volume every 6 months using orchidometer or ultrasound 2, 4
• Surgical intervention is strongly recommended if persistent testicular size difference >2 mL or 20% is confirmed on two subsequent visits 6 months apart 1, 2
• This approach prevents progressive testicular damage that can occur during adolescence 2, 4
• The size asymmetry threshold is critical because it indicates ongoing testicular dysfunction that may worsen without intervention 1

Men with Chronic Testicular Pain

• Varicocelectomy or gonadal vein embolization should be offered for chronic orchialgia attributed to varicocele 2
• Treatment achieves complete pain relief in 87% of patients at 39 months follow-up after embolization 2
• Pain is a legitimate indication for treatment regardless of varicocele size when other causes have been excluded 2

Important Caveats and Red Flags

When to Obtain Imaging

• New-onset, large, or non-reducible varicoceles require abdominal/pelvic imaging to exclude secondary causes such as renal masses or venous obstruction 2
• Right-sided or bilateral varicoceles, especially if the right side is large, warrant imaging to exclude retroperitoneal pathology 2
• These atypical presentations may indicate underlying malignancy or venous obstruction rather than primary varicocele 2

Treatment Contraindications

• Do not treat subclinical (non-palpable) varicoceles detected only on ultrasound, as this does not improve outcomes 1, 3
• Do not treat varicoceles in infertile men who have normal semen analysis, as there is no demonstrated benefit 1

Treatment Modalities When Indicated

When treatment criteria are met, several approaches exist:

• Microsurgical varicocelectomy is considered the gold standard with lowest recurrence rates 3, 5
• Percutaneous embolization offers a minimally invasive alternative requiring only minimal sedation, with 82.8% success for left-sided varicoceles 6, 7
• Laparoscopic varicocelectomy is particularly useful for bilateral varicoceles 6

The choice of technique should consider patient factors, but microsurgical approaches generally provide superior outcomes with fewer complications compared to open surgery 3, 6