Treated by interventional radiology embolization, not same as scrotal varicocele
Not covered by scrotal varicocele management pathway
Geriatric
Varicocele in older men
New-onset varicocele in men over 40 years is a red flag
Must exclude secondary cause including retroperitoneal malignancy
CT abdomen/pelvis mandatory
Fertility considerations in older men
Advanced paternal age associated with decreased fertility and increased genetic risk
ART with ICSI may be more appropriate than varicocele repair depending on female partner age
Surgical risk considerations
Microsurgical repair generally well-tolerated
Cardiovascular and anesthetic risk assessment for any surgical approach
Percutaneous embolization preferred in high surgical risk patients
Pediatrics
Adolescent varicocele
Prevalence increases with puberty onset
Approximately 15% of adolescent males by late puberty
Cannarella et al. Journal of Clinical Medicine 2019
Monitoring protocol
Annual follow-up with orchidometer or ultrasound volumetry
Semen analysis at Tanner V stage
Continue monitoring until paternity achieved or surgery performed
Treatment threshold in adolescents
Ipsilateral testicular volume loss greater than or equal to 20%
Or abnormal semen analysis at Tanner V
Kolon. Journal of Urology 2015; Beland et al. Fertility and Sterility 2026
Peak retrograde flow on Doppler
PRF greater than 38 cm/s associated with higher risk of testicular dysfunction
Cannarella et al. Journal of Clinical Medicine 2019
Used alongside volume asymmetry for treatment decision in adolescents
Surgical outcomes in adolescents
Catch-up testicular growth expected post-repair if volume asymmetry present
Microsurgical approach preferred for lowest recurrence
Prepubertal varicocele
Rare; secondary cause more likely
CT abdomen/pelvis to exclude retroperitoneal pathology
Background
Epidemiology
Prevalence and demographics
General male population
Approximately 15% of all men have varicocele
Left-sided in 85 to 90% of cases due to left gonadal vein anatomy
Infertility population
35% prevalence in men with primary infertility
Up to 80% prevalence in men with secondary infertility
Langan and Puente. American Family Physician 2022
Age of onset
Peak onset 15 to 25 years corresponding to puberty
Varicoceles are uncommon before puberty
Bilateral varicocele
Less common; bilateral disease may suggest venous obstruction from secondary cause
Right-sided alone is rare and mandates secondary workup
Pathophysiology
Venous anatomy and failure
Left testicular vein anatomy
Drains into left renal vein at right angle creating higher hydrostatic pressure
Right testicular vein drains directly into IVC at an oblique angle
Venous valve insufficiency
Incompetent or absent valves allow retrograde blood flow
Pampiniform plexus dilates in response to increased venous pressure
Spermatogenic impairment mechanisms
Scrotal hyperthermia from increased venous blood
Normal testicular temperature 2 to 4 degrees Celsius below core body temperature
Kang et al. Seminars in Cell and Developmental Biology 2022
Reflux of adrenal and renal metabolites via left renal vein
Catecholamines and cortisol toxic to spermatogenesis
Testicular hypoxia from venous stasis
Impairs oxidative phosphorylation and Sertoli cell function
Increased reactive oxygen species
Sperm DNA fragmentation results
Impairs sperm motility and fertilization capacity
Hormonal effects
Leydig cell dysfunction
Reduced testosterone production in larger or bilateral varicoceles
Elevated LH with normal or low testosterone suggests compensated hypogonadism
Sertoli cell dysfunction
Elevated FSH reflects impaired spermatogenesis
Reduced inhibin B in severe cases
Therapeutic Considerations
Evidence base for treatment
Cochrane 2021 systematic review
Surgical or radiological treatment improves pregnancy rates in subfertile men with palpable varicocele
Persad et al. Cochrane Database of Systematic Reviews 2021
AUA/ASRM Guideline Part II 2021
Repair indicated only for palpable varicocele with infertility and abnormal semen parameters
Subclinical varicocele repair is not recommended
Fertility and Sterility Committee Opinion 2014
Foundational guideline for varicocele and infertility management
Requires female partner evaluation before recommending repair
Treatment expectations
Semen parameter improvement
Improvement in sperm count, motility, and morphology in majority post-repair
Time to measurable improvement approximately 3 to 6 months
Spontaneous pregnancy
Improved spontaneous pregnancy rates with surgical repair vs. observation
ART success rates also improve post-repair in some studies
Testosterone recovery
Some improvement in testosterone levels post-repair in hypogonadal men
Not a primary indication for repair in absence of infertility
Repair technique comparison
Microsurgical subinguinal varicocelectomy
Gold standard: lowest recurrence approximately 1%, lowest hydrocele rate
Inguinal microsurgical: similar outcomes
Laparoscopic varicocelectomy
Higher recurrence than microsurgical approaches
Not preferred as first-line
Percutaneous embolization
Comparable efficacy to surgical approaches
Preferred for recurrent varicocele post-surgery
Patient Discharge Instructions
copy discharge instructions
Diagnosis and explanation
You have been evaluated for a varicocele, which is an enlargement of the veins within the scrotum
This is a common condition affecting approximately 15% of men
It is not dangerous on its own but may affect fertility in some men
Most varicoceles do not require immediate treatment
Your doctor will refer you to a urologist if treatment is needed
Treatment decisions are based on symptoms, fertility goals, and testicular size
Activity and self-care
Wear supportive underwear to reduce scrotal discomfort
Avoid prolonged standing when pain is present
Avoid excessive heat exposure to the scrotum
Pain management at home
Ibuprofen 400 to 600 mg every 6 to 8 hours with food as needed for pain
Acetaminophen 500 to 1000 mg every 6 hours as alternative
Return to emergency department immediately if
Sudden severe testicular pain develops
This may be a sign of testicular torsion, a surgical emergency
Do not wait until morning; seek emergency care immediately
New hard lump develops in the testicle
May indicate testicular cancer
Requires urgent evaluation
Scrotal swelling rapidly worsens or becomes red and hot
May indicate infection or serious condition
Weight loss, night sweats, or fever develop
May indicate an underlying malignancy
Follow-up instructions
Attend your urology referral appointment as arranged
Bring any prior semen analysis results if available
Notify your urologist of any fertility concerns
If fertility is a concern, your partner should also be evaluated
A semen analysis will likely be arranged by your urologist
Fertility evaluation is a joint process
References
Guidelines and key sources
Primary clinical guidelines
Schlegel PN, Sigman M, Collura B, et al. Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline Part II. Fertility and Sterility. 2021
AUA/ASRM criteria for varicocele repair in infertile men
Subclinical varicocele repair not recommended
Report on Varicocele and Infertility: A Committee Opinion. Fertility and Sterility. 2014
Foundational guideline for varicocele and fertility evaluation
Requires female partner assessment before recommending repair
Persad E, O'Loughlin CA, Kaur S, et al. Surgical or Radiological Treatment for Varicoceles in Subfertile Men. Cochrane Database of Systematic Reviews. 2021
Supports treatment benefit in subfertile men with palpable varicocele
Informs surgical vs. radiological approach comparison
Khatri G, Bhosale PR, Robbins JB, et al. ACR Appropriateness Criteria Newly Diagnosed Palpable Scrotal Abnormality. Journal of the American College of Radiology. 2022
Color Doppler ultrasound as first-line imaging
CT criteria for secondary varicocele evaluation
Supporting references
Secondary sources
Langan RC, Puente MEE. Scrotal Masses. American Family Physician. 2022
Clinical approach to scrotal mass evaluation
Alarm features for malignancy and torsion
Kang C, Punjani N, Lee RK, Li PS, Goldstein M. Effect of Varicoceles on Spermatogenesis. Seminars in Cell and Developmental Biology. 2022
Pathophysiology of varicocele-induced spermatogenic impairment
Scrotal hyperthermia and reactive oxygen species mechanisms
Cannarella R, Calogero AE, Condorelli RA, et al. Management and Treatment of Varicocele in Children and Adolescents: An Endocrinologic Perspective. Journal of Clinical Medicine. 2019
Adolescent monitoring and treatment thresholds
Peak retrograde flow prognostication
Beland LE, Davis MF, Aiyar S, et al. Adolescent Varicocele: A Surgical Conundrum. Fertility and Sterility. 2026
Updated adolescent varicocele management guidance
Takacs T, Szabo A, Kopa Z. Recent Trends in the Management of Varicocele. Journal of Clinical Medicine. 2025
Contemporary surgical technique comparison and outcomes
Microsurgical approaches vs. percutaneous embolization
Kolon TF. Evaluation and Management of the Adolescent Varicocele. Journal of Urology. 2015
Volume asymmetry threshold for adolescent intervention
Crawford P, Crop JA. Evaluation of Scrotal Masses. American Family Physician. 2014
Systematic approach to scrotal mass differential diagnosis
Sweet DE, Feldman MK, Remer EM. Imaging of the Acute Scrotum. Abdominal Radiology. 2020
Ultrasound protocol for acute scrotal disorders
Torsion versus varicocele imaging differentiation
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