What is the best course of treatment for a 20-year-old male with a large 0.5cm left varicocele (varicose vein of the spermatic cord) and associated pain, as well as small epididymal cysts (fluid-filled sacs near the testes) on both testes?

Management of Painful Left Varicocele with Epididymal Cysts in a 20-Year-Old Male

For a 20-year-old male with a painful left varicocele, microsurgical varicocelectomy is the recommended treatment, while the small epididymal cysts should be managed conservatively with observation alone. 1, 2

Varicocele Management

Indications for Surgical Treatment

The European Association of Urology strongly recommends treating clinical (palpable) varicoceles in young men when associated with:

• Pain that significantly impacts quality of life 3
• Abnormal semen parameters in the context of infertility 1, 2
• Testicular size discrepancy >2 mL or 20% confirmed on two visits 6 months apart 4, 2

Pain alone is a valid indication for varicocelectomy when it significantly affects daily activities, as conservative measures (scrotal support, NSAIDs) often provide inadequate relief. 3

Surgical Approach

Microsurgical varicocelectomy is the preferred technique because it:

• Results in improvement in both symptoms and testicular function 2
• Has lower recurrence rates compared to other approaches 2
• Can address bilateral pathology and other scrotal comorbidities through a single scrotal access 5

Important Diagnostic Considerations

• Scrotal Doppler ultrasound should be performed to confirm varicocele grade, evaluate blood flow patterns, and assess testicular size and texture 2, 3
• The ultrasound serves as both diagnostic confirmation and baseline documentation before treatment 3
• Physical examination showing a prominent pampiniform plexus is diagnostic, but ultrasound provides objective grading 2

Epididymal Cyst Management

Conservative Management is Standard

Small epididymal cysts (<5 cm) should be managed conservatively with observation, regardless of whether they are symptomatic or not. 6, 7, 8

The rationale for conservative management includes:

• Epididymal cysts are not associated with impaired semen parameters among men presenting for fertility evaluation 8
• They have a benign natural history with good evolution in conservatively managed cases 7
• Surgery carries risks including postoperative hematoma, edema, sustained pain, and potential seminal tract obstruction 9

When to Consider Intervention

Intervention for epididymal cysts should only be considered if:

• Cysts exceed 5 cm in diameter AND are symptomatic 6
• Complications develop (infection, rupture, severe pain) 7
• Percutaneous sclerotherapy with 3% Polidocanol is preferred over surgery when intervention is needed, with 84% success rate and minimal complications 6

Critical Caveat for Young Men

For men with future fertility plans, surgical intervention on epididymal cysts should be avoided due to risk of seminal tract obstruction. 9 If surgery becomes absolutely necessary, microscopic epididymal exploration and cystectomy should be performed before cysts reach 0.8-0.9 cm diameter to preserve epididymal patency. 9

Follow-Up Protocol

Post-Varicocelectomy Monitoring

• Follow-up scrotal ultrasound should be performed post-varicocelectomy to confirm procedural success and resolution of venous reflux 3
• Semen parameter improvements typically take 3-6 months (two spermatogenic cycles) to manifest 4

Epididymal Cyst Surveillance

• Routine surveillance imaging for stable epididymal cysts is NOT indicated 3
• Physical examination is sufficient for monitoring 3
• Repeat imaging only warranted for: new acute severe pain, palpable mass changes, or testicular enlargement suggesting alternative pathology 3

Common Pitfalls to Avoid

• Do not treat subclinical (non-palpable) varicoceles identified only on ultrasound, as treatment does not improve semen parameters or fertility rates 1, 2
• Do not perform routine surveillance ultrasounds for stable bilateral varicoceles with intermittent pain, as pain alone does not require serial imaging 3
• Do not surgically remove small asymptomatic epididymal cysts, especially in young men with potential future fertility concerns 7, 9, 8
• Avoid attributing all scrotal symptoms to the varicocele or cysts—ensure thorough evaluation to exclude testicular torsion, epididymoorchitis, or testicular tumors, particularly given that infertile men have 1.91 times higher risk of testicular cancer 1