What are the medical treatment options for varicocele?

From the Guidelines

Varicoceles are typically treated with surgical or minimally invasive procedures rather than medications, and treatment is generally recommended only when a varicocele causes pain, testicular atrophy, or infertility. The primary approach to managing varicoceles involves addressing the underlying cause of the condition, which is often related to dysfunctional valves in the spermatic veins. According to the most recent evidence from 1, varicoceles can be effectively treated with endovascular therapy, such as gonadal vein embolization, which has been shown to provide complete pain relief in 87% of patients at 39 months.

Treatment Options

• Varicocelectomy (surgical ligation of the affected veins)
• Varicocele embolization (a minimally invasive procedure to block blood flow through the affected veins)
• Supportive measures, such as wearing snug underwear or athletic supporters to relieve pressure, and applying cold compresses when discomfort occurs
• Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-600mg every 6-8 hours) or naproxen (220-440mg twice daily) for temporary pain relief

Considerations for Treatment

• The presence of abnormal semen parameters and minimal/no identified female factor, including consideration of age and ovarian reserve, may indicate the need for varicocele treatment, as suggested by 1
• The treating physician’s experience and expertise, including evaluation of both partners, together with the options available, should determine the approach to varicocele treatment
• IVF with or without ICSI may be considered the primary treatment option when such treatment is required to treat a female factor, regardless of the presence of varicocele and abnormal semen parameters, as noted in 1

From the Research

Medical Treatment Options for Varicocele

• Varicocele treatment options include open varicocelectomy, laparoscopic varicocelectomy, robotic surgery, microsurgical varicocelectomy, and percutaneous retrograde and anterograde venous embolization/sclerotherapy 2
• The ultimate goal of varicocele treatment is the occlusion of the dilated veins that drain the testis, which can be achieved through various techniques, including surgical repair and percutaneous embolization 3

Surgical Techniques

• Microsurgical varicocelectomy has gained popularity among experts in male reproductive medicine due to its superior surgical outcomes 2
• Open varicocelectomy and laparoscopic varicocelectomy are also effective treatment options for varicoceles 2

Minimally Invasive Techniques

• Percutaneous embolization of the internal spermatic vein is a minimally invasive technique that offers a rapid recovery and can be successfully accomplished in approximately 90% of attempts 3
• However, percutaneous embolization demands interventional radiologic expertise and has potential serious complications, including vascular perforation, coil migration, and thrombosis of pampiniform plexus 3

Comparison of Treatment Options

• Varicocele correction is a more cost-effective therapeutic modality than both intrauterine insemination (IUI) and in vitro fertilization (IVF) for affected couples 4
• Bilateral varicoceles are best managed with a primary microsurgical approach, where technical failure rates are expected to be less than 5% based on published data 5
• Men with unilateral left-sided varicoceles can be offered both surgical and embolization options, as they have similar failure rates, but with embolization offering some clear advantages to the patient 5