What is the treatment for a patient with testicular pain due to varicocele?

Treatment of Varicocele-Associated Testicular Pain

For a patient with testicular pain due to varicocele, begin with conservative non-surgical management; if pain persists and significantly impacts quality of life, proceed with microsurgical varicocelectomy, which resolves pain in approximately 80% of carefully selected cases with clinically palpable varicocele. 1

Initial Evaluation and Diagnosis

• Confirm the diagnosis through physical examination in both supine and standing positions with Valsalva maneuver—an increase in spermatic cord diameter during Valsalva is diagnostic 2, 3
• Only treat clinical (palpable) varicoceles; do not treat subclinical (non-palpable) varicoceles identified only on ultrasound, as treatment does not improve outcomes 4, 2
• Scrotal Doppler ultrasound should be performed to confirm varicocele grade, evaluate blood flow patterns, and assess testicular size, particularly useful in obese patients where examination is difficult 2
• The pain is typically described as dull, aching, or throbbing in the testicle, scrotum, or groin; rarely acute or sharp 1

Conservative Management (First-Line Approach)

• Start with a conservative, non-surgical approach and observation period 1
• Conservative measures should be attempted before considering surgical intervention for pain alone 5
• Pain alone does not require serial imaging to monitor varicocele progression—physical examination is sufficient for monitoring stable varicoceles 5

Surgical Intervention Criteria

Proceed with varicocelectomy when:

• Pain significantly impacts quality of life despite conservative management 5, 1
• The varicocele is clinically palpable (not subclinical) 4, 2
• The patient has been carefully selected and counseled about realistic expectations 1

Additional strong indications for surgery (even without pain):

• Infertile men with clinical varicocele, abnormal semen parameters, and otherwise unexplained infertility when the female partner has good ovarian reserve 4, 3
• Adolescents with persistent testicular size difference >2 mL or 20%, confirmed on two visits 6 months apart 4, 2

Surgical Technique Selection

• Microsurgical varicocelectomy (inguinal or subinguinal approach) is the reference standard technique, offering lower recurrence and complication rates compared to high surgical approaches or surgery without magnification 3
• Percutaneous retrograde embolization is a minimally invasive alternative with satisfactory outcomes and rare complications 3, 6
• Laparoscopic approaches are more commonly used in adolescents but microsurgical techniques remain optimal for most adult cases 3, 7

Expected Outcomes and Follow-Up

• Varicocelectomy resolves testicular pain in approximately 80% of carefully selected candidates with clinically palpable varicocele 1
• Predictors of surgical success include: varicocele grade, nature and duration of pain, body mass index, prior conservative management, and surgical method used 1
• Post-varicocelectomy ultrasound should be performed to confirm procedural success and resolution of venous reflux 5
• For fertility-related outcomes, improvements in semen parameters typically occur after 3-6 months (1-2 spermatogenic cycles) 3, 8

Critical Pitfalls to Avoid

• Do not treat subclinical varicoceles—treatment of non-palpable varicoceles identified only on ultrasound does not improve pain, semen parameters, or fertility rates 4, 2, 5
• Do not perform routine surveillance imaging for stable varicoceles with intermittent pain—physical examination is sufficient 5
• Do not treat varicocele in infertile men with normal semen analysis 4
• The presence of reflux on ultrasound alone does not determine clinical significance, as varicoceles affect 15% of normal males with most never requiring treatment 2