Approach

Treatment of varicocele, when necessary, is with surgical or nonsurgical repair. The decision to perform repair depends on both the patient's age and the impact on fertility.

Varicocele repair techniques

Management options include: embolization; antegrade or retrograde sclerotherapy; and ligation (open retroperitoneal, inguinal, laparoscopic, or microsurgical subinguinal).[31][46] Varicocele treatment will fully eliminate more than 90% of varicoceles (98% if microscopic subinguinal approach is used).[29][47]

Choice of technique is influenced by the surgeon's experience and the patient's surgical history. If the patient has had prior inguinal surgery, a microsurgical subinguinal approach may be best to ensure that the testicular artery is completely preserved (to avoid testicular atrophy).[48]

Most urologists currently employ an inguinal or subinguinal surgical approach, with the assistance of an operative microscope. Percutaneous embolization may be associated with less postoperative pain; however, the recurrence rates are higher.[49]

Microsurgical subinguinal varicocele ligation has lower rates of complications and recurrence compared with percutaneous or open nonmicrosurgical approaches; it is also more likely to improve pregnancy rates.[33][49][50][51]​​​​​​​​​ While the microsurgical subinguinal approach is preferred in adults, further research is required to confirm the optimal technique in adolescents.[23][52]

Adolescents with varicocele

For adolescents with subclinical or grade I varicocele, no treatment is necessary. Reassurance should be given to both patient and parent or caregiver.

Observation with serial exams is best suited for adolescents with symmetric testes (or <20% size difference between testes) and a grade II or III varicocele. The grade of the varicocele is not predictive of the need for surgical intervention.[23]​​

Indications for treatment of adolescent varicocele

Available data do not suggest that adolescent varicocele is progressive.[53]​ As such, the primary indication for treatment in this age group is testicular growth arrest. The examiner must follow testicular size on yearly examinations.[23]​ If a size discrepancy is detected, a confirmatory exam should be performed 6 months later, as normal, asynchronous growth can sometimes lead to asymmetry.[45]​ One study showed that, of adolescent boys who present with a grade II or III varicocele and testes of equal size, about 25% will ultimately develop testicular growth arrest.[54] 

The most commonly accepted indication for correction of an adolescent varicocele is >2 cm³ or 20% size difference between the affected and normal testis. In these patients, the goal of varicocele repair is to allow for ipsilateral testicular "catch-up" growth and potentially improving overall testicular health. Patients can expect a 50% to 80% chance of ipsilateral catch-up growth of the affected testis following surgery; this may take up to 6 months.[55] ​Significant pain is rare, and is an indication for repair.​[56]

Obtaining a semen sample in an adolescent may be challenging and must be addressed on an individual basis. However, if available, abnormal semen analysis in an older adolescent may be an indication for consideration of repair.[23][45]

Patients and parents or caregivers should be counseled about the potential for reduced fertility in later life if the varicocele is not treated.[57] There is evidence that varicocele correction in adolescents increases the affected testis volume and sperm concentration.[58][59] However, studies including long-term outcomes (such as fertility) are lacking, and there is no consensus on the optimum timing for treatment.​[45][58]

Adults with varicocele

For subclinical or grade I varicocele, no treatment is necessary. If fertility is a concern, semen analysis may be offered. Adult men with a palpable, asymptomatic varicocele and normal semen findings can be observed with serial semen analyses every 1 to 2 years.[29] 

Historically, the repair of a varicocele to improve male fertility was advised only when the female partner had a treatable form of infertility that could allow for natural conception. However, some patients may now pursue repair even if the couple is planning to use assisted reproductive techniques due to possible improved pregnancy and live birth outcomes.[60][61][62]

While surgical varicocelectomy is controversial, reviews limited to patients with palpable varicocele and abnormal semen parameters suggest that the procedure improves semen parameters, particularly concentration and motility.[33][46][49]​​​​​ The degree of improvement, however, likely depends on the size of the varicocele.[63] For men with unexplained infertility, abnormal semen parameters, and clinically palpable varicoceles, varicocele repair is recommended.[25]​[31]​​​​​​

Pain can occur in up to 30% of men with clinically significant varicoceles.[39]​ Where it does occur, repair should be considered.[56]

Although previously thought to be an uncommon cause of hypogonadism, varicocele has been increasingly linked to Leydig cell dysfunction.[1]​[30]​​​​ For men with palpable varicoceles and hypogonadism, surgical repair may improve testosterone levels.[64]​ Varicocelectomy can be offered to these patients, although they should be counseled on the lack of robust, prospective, randomized studies.[31]

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