From the Guidelines
Varicocele management should prioritize a conservative approach for mild cases and surgical intervention for symptomatic or fertility-affecting varicoceles, with microsurgical varicocelectomy being the gold standard for treatment due to its lower complication rates and higher success rates, as supported by the most recent guidelines 1.
Key Considerations
- For mild, asymptomatic varicoceles, observation is often recommended with regular follow-up examinations.
- When treatment is necessary, surgical options include microsurgical varicocelectomy, which involves ligating the dilated veins while preserving the testicular artery and lymphatics.
- Alternatively, percutaneous embolization offers a less invasive approach where a radiologist occludes the affected veins using coils or sclerosing agents, with studies showing that gonadal vein embolization is effective for relieving orchialgia, with 87% of 154 patients having complete pain relief at 39 months 1.
Fertility Considerations
- Treatment is particularly indicated for men with fertility issues, as varicoceles can impair sperm production and quality by increasing testicular temperature and causing oxidative stress.
- The correction of palpable varicoceles results in improvement in both semen quality and fertility, whereas treatment of non-palpable varicoceles is not associated with improvement in either semen parameters or fertility rates 1.
Diagnostic Approaches
- Scrotal ultrasound can be used before repair to confirm the presence of varicocele and also following correction to determine procedural success, in the context of shared decision-making with the patient.
- Clinicians should not perform transrectal ultrasonography (TRUS) or pelvic MRI as part of the initial evaluation of the infertile male, unless there is suspicion of ejaculatory duct obstruction or other specific conditions 1.
Management Strategies
- Pain management for symptomatic varicoceles may include NSAIDs like ibuprofen (400-600mg three times daily) for short-term relief.
- Supportive measures such as scrotal support, avoiding prolonged standing, and regular exercise can help manage discomfort.
- Post-treatment, patients should expect gradual improvement in symptoms and potential enhancement in semen parameters within 3-6 months, though regular follow-up is essential to monitor for recurrence or complications.
From the Research
Scrotum Varicocele Management
- Varicocele is an abnormal dilation of the pampiniform plexus of veins in the scrotum, affecting approximately 15% of males, and is the most common etiology of male factor infertility 2.
- The key to successful varicocelectomy is to ligate all spermatic veins while protecting the testicular arteries and spermatic lymphatic vessels from damage 3.
- Conventional high ligation of varicocele has a high postoperative recurrence rate due to the difficulty in ligating small veins, including branches of spermatic veins and collateral veins 3.
Treatment Options
- Combination of high ligation and intraoperative embolization using polidocanol has been shown to reduce postoperative recurrence rate compared to traditional high ligation 3.
- Occluding balloon embolization (OBE) has been compared to conventional laparoscopic ligation (LL) and has been found to have a slight advantage in terms of hospital stay and full recovery to normal activity of patients 4.
- Microsurgical subinguinal approach is considered the gold standard for adult population, but its superiority for adolescent population has yet to be confirmed 2.
- Embolization is an attractive alternative to surgery, with a technical failure rate of less than 5% for unilateral left-sided varicoceles, but higher failure rates for bilateral varicoceles 5.
Diagnostic and Therapeutic Challenges
- Diagnosis of varicocele in adolescents is challenging, and it is difficult to predict which adolescent will ultimately show diminished testicular function in adolescence or adulthood 2, 6.
- Treatment of varicocele in adolescents is often laparoscopic, with the goal of preventing testicular damage and improving fertility prospects 6.
- Controversy remains as to which patients to treat, when to initiate treatment, and what type of treatment is best, highlighting the need for improved diagnostic accuracy and surveillance strategies 2, 6.