What are the implications of an epididymal head cyst and a varicocele on fertility and testicular health?

Clinical Implications of Epididymal Head Cyst and Varicocele

Epididymal head cysts have no impact on fertility or testicular health and require no treatment, while varicoceles significantly impair fertility in men with abnormal semen parameters and should be surgically corrected when clinically indicated. 1, 2

Epididymal Head Cyst: Benign and Clinically Insignificant

Impact on Fertility

• Epididymal cyst lesions (including epididymal cysts and spermatoceles) show no association with impaired semen parameters including sperm concentration, motility, morphology, or total motile sperm count. 2
• Among 861 men evaluated for fertility, those with epididymal cysts (19% unilateral right, 22% unilateral left, 13% bilateral) demonstrated no statistically significant differences in any semen parameter compared to men without cysts. 2
• Neither the size nor laterality of epididymal cysts correlates with semen quality. 2

Management Approach

• Conservative management with observation is appropriate for all asymptomatic epididymal cysts in the fertility evaluation setting. 2
• Surgical intervention is only warranted if the cyst causes pain or significant discomfort, not for fertility concerns. 2, 3

Varicocele: Significant Fertility and Hormonal Implications

Impact on Fertility and Testicular Function

• Varicoceles are present in 35-40% of men presenting with infertility compared to only 15% of the general male population, establishing a clear causal relationship with fertility impairment. 4, 5
• Higher varicocele grades (particularly grade 3) correlate with progressively worse semen parameters and greater testicular dysfunction, with mean maximal vein diameters increasing from 2.5 mm (normal) to 6.6 mm (grade III). 5
• The pathophysiology involves multiple mechanisms: elevated scrotal temperature, testicular hypoxia, reflux of toxic metabolites, and increased sperm DNA damage. 4

Hormonal Alterations

• Varicoceles can cause decreased testosterone levels and elevated FSH and LH levels, which may normalize after varicocelectomy. 6
• Men with varicoceles and FSH levels above 7.6 IU/L likely have underlying spermatogenic impairment, though levels below 11.7 mIU/L predict favorable surgical outcomes. 4
• Decreased inhibin-B and anti-Müllerian hormone levels indicate impaired Sertoli cell function in varicocele-bearing patients. 6

Treatment Indications (Strong Recommendations)

Treat varicocele when ALL of the following criteria are met: 1

1. Clinical (palpable) varicocele is present - do NOT treat subclinical varicoceles detected only on ultrasound
2. Abnormal semen parameters are documented on at least two analyses
3. Otherwise unexplained infertility exists in the couple
4. Female partner has good ovarian reserve - critical because waiting for sperm recovery (3-6 months) may compromise outcomes if female fertility is limited

Additional treatment indication for adolescents: 1

• Persistent testicular size difference >2 mL or 20% confirmed on two visits 6 months apart

Do NOT Treat Varicocele When: 1

• Semen analysis is normal (regardless of varicocele grade)
• Varicocele is subclinical (non-palpable, detected only by ultrasound)
• These scenarios show no improvement in fertility rates with treatment

Special Considerations for Azoospermia

• Varicocelectomy may restore sperm to the ejaculate in men with non-obstructive azoospermia, particularly those with hypospermatogenesis on testicular biopsy. 4
• The evidence quality is low, requiring thorough discussion of risks and benefits before proceeding. 4

Diagnostic Evaluation

• Physical examination of the warmed scrotum with Valsalva maneuver is the primary diagnostic method - an increase in spermatic cord diameter during Valsalva confirms varicocele. 1, 5
• Scrotal Doppler ultrasound should be reserved for cases where physical examination is indeterminate (e.g., obese patients) or to confirm grade. 5
• Do not routinely use ultrasound to screen for subclinical varicoceles as their treatment does not improve outcomes. 1, 5

Expected Outcomes After Treatment

• Improvements in semen parameters and hormonal levels typically require 3-6 months (two complete spermatogenic cycles) to manifest. 4
• Microsurgical varicocelectomy is the preferred technique, improving both semen quality and fertility rates. 5

Critical Pitfall to Avoid

The most common error is treating subclinical varicoceles or varicoceles in men with normal semen analysis - this provides no benefit and exposes patients to unnecessary surgical risk. 1, 5 Always confirm both clinical varicocele presence AND abnormal semen parameters before recommending surgery.