Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

adolescent

1st line – reassurance

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ACUTE
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adolescent
|
subclinical or grade I varicocele
1st line – 

reassurance

No active treatment is necessary. Reassurance should be given to both patient and parent or caregiver.

1st line – observation

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ACUTE
|
adolescent
|
grade II or III varicocele: <20% size difference or symmetric testes
1st line – 

observation

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

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]

1st line – varicocele repair

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ACUTE
|
adolescent
|
grade II or III varicocele: asymmetric (>2 cm³ or >20% difference), or with significant pain, or abnormal semen parameters
1st line – 

varicocele repair

The primary indication for treatment in this age group is testicular growth arrest (>2 cm³ or 20% size difference between the affected and normal testis). Significant pain is rare, and is an indication for treatment.​[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]

Varicocele repair techniques 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 the most appropriate to ensure the testicular artery is preserved (to avoid atrophy). While the microsurgical subinguinal approach is preferred in adults, further research is required to confirm the optimal technique in adolescents.[23][52]

In these patients, the goal of varicocele repair is to allow for ipsilateral testicular "catch-up" growth and potentially improving overall testicular health. There is evidence that varicocele correction in adolescents increases the affected testis volume and sperm concentration.​[58][59]

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] Studies including long-term outcomes (such as fertility) are lacking.[45][58]

adult

1st line – reassurance

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ACUTE
|
adult
|
subclinical or grade I varicocele with normal semen parameters
1st line – 

reassurance

Once semen findings have been shown to be normal these patients can be reassured that no active treatment is necessary.

1st line – observation

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ACUTE
|
adult
|
grade II or III varicocele: asymptomatic or with normal semen parameters
1st line – 

observation

Adult men with a palpable, asymptomatic varicocele and normal semen parameters can be observed with serial semen analyses every 1 to 2 years.[29]

For men with unexplained infertility, abnormal semen parameters, and clinically palpable varicoceles, varicocele repair is recommended.[25]​[31]​​

1st line – varicocele repair

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ACUTE
|
adult
|
grade II or III varicocele and symptomatic; or grade I to III with abnormal semen parameters
1st line – 

varicocele repair

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

For men with unexplained infertility, abnormal semen parameters, and clinically palpable varicoceles, variceal repair is recommended.[25]​[31]​​​​

An improvement in semen parameters, particularly concentration and motility, can be seen with repair of any clinically palpable varicocele.[33]​​[46]​​[49]​​​ The degree of improvement, however, likely depends on the size of the varicocele.​​​[63]

Historically, the repair of a varicocele to improve 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]

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]

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

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]

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 the most appropriate to ensure the testicular artery is 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]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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