What is the next best step in managing a patient with varicocele?

Management of Varicocele

The next best step depends on whether the patient has infertility, symptoms, or is an adolescent, but for the most common scenario—an infertile man with a palpable varicocele and abnormal semen parameters—treatment with varicocelectomy (preferably microsurgical subinguinal or inguinal approach) is recommended to improve fertility outcomes. 1

Initial Assessment and Risk Stratification

Clinical Evaluation

• Perform physical examination in both supine and standing positions to confirm the presence of a palpable (clinical) varicocele, as this is essential for determining treatment candidacy 1, 2
• Document testicular size using orchidometer or ultrasound, particularly noting any size discrepancy between testes 3
• Obtain semen analysis to assess sperm parameters (concentration, motility, morphology) 1

When to Use Imaging

• Scrotal Doppler ultrasound is indicated when physical examination is difficult (e.g., obese patients) or to confirm varicocele grade 4
• Do NOT routinely use ultrasound to identify non-palpable (subclinical) varicoceles, as treating these does not improve outcomes 1, 4
• Consider abdominal/pelvic imaging if the varicocele is right-sided, bilateral with new onset, or non-reducible when supine (to exclude retroperitoneal malignancy), especially in men over 40 2

Treatment Indications by Clinical Scenario

Infertile Men (Most Common Indication)

Treat varicocele when ALL of the following are present: 1

• Clinical (palpable) varicocele on examination
• Abnormal semen parameters
• Otherwise unexplained infertility
• Female partner has good ovarian reserve

Do NOT treat varicocele in: 1

• Men with normal semen analysis
• Men with only subclinical (non-palpable) varicocele detected on ultrasound

Additional Treatment Considerations

• Varicocelectomy may be considered in men with elevated sperm DNA fragmentation, recurrent pregnancy loss, or failure of assisted reproductive techniques despite otherwise unexplained infertility 1
• Microsurgical subinguinal or inguinal varicocelectomy is the optimal approach with superior outcomes and low complication rates 5, 6

Adolescents

Offer surgery for varicocele when: 1

• Persistent testicular size difference >2 mL (or >20%) on the affected side
• Confirmed on two visits performed 6 months apart

This approach balances the risk of future fertility problems against overtreatment in this population 3

Symptomatic Patients

• Refer to urology if the patient has significant pain or bothersome symptoms 2
• Pain alone may be an indication for treatment, as symptoms can correlate with deteriorating semen parameters 6

Post-Treatment Expectations

• Expect 3-6 months for semen parameter improvement after varicocelectomy 5
• Consider assisted reproductive technology if infertility persists after this interval, particularly in older couples 5

Critical Pitfalls to Avoid

• Never treat subclinical varicoceles—this does not improve fertility rates and represents overtreatment 1, 4
• Do not delay abdominal imaging in men over 40 with acute-onset or right-sided varicocele, as this may indicate retroperitoneal malignancy 2
• Do not perform varicocelectomy in men with normal semen analysis, as there is no proven benefit 1