Diagnosis and Treatment of Varicocele

Diagnosis and Evaluation

The European Urology guideline recommends that a prominent pampiniform plexus is diagnostic of varicocele, which should be treated with microsurgical varicocelectomy in infertile men with abnormal semen parameters to improve fertility rates 1
Scrotal Doppler ultrasound should be performed to confirm the grade of varicocele, evaluate blood flow patterns, and is particularly useful in patients where physical examination is difficult (e.g., obese patients) 2
Routine use of ultrasonography to identify non-palpable varicoceles is discouraged as treatment of these varicoceles is not associated with improvement in semen parameters or fertility rates 3, 2

The European Urology guideline recommends treating varicocele in infertile men with clinical varicocele, abnormal semen parameters, and otherwise unexplained infertility, especially when the female partner has good ovarian reserve 1
The European Urology guideline also recommends treating varicocele in adolescents with varicocele associated with a persistent small testis (size difference >2 ml or 20%), confirmed on two subsequent visits 6 months apart 1
Microsurgical varicocelectomy appears to result in improvement in both semen quality and fertility, with scrotal ultrasound used before repair to confirm the presence of varicocele and after correction to determine procedural success 3
Varicocelectomy may be considered in men with otherwise unexplained infertility and those with failure of assisted reproductive techniques, including recurrent pregnancy loss and failure of embryogenesis and implantation 1
Onco-TESE (testicular sperm extraction) at the time of radical orchidectomy should be offered in men with testicular cancer and azoospermia or severe abnormalities in semen parameters 1

An increase in diameter of the spermatic cord during the Valsalva maneuver is the finding that indicates a varicocele, according to the European Association of Urology 4
Higher varicocele grades are associated with worse semen parameters and greater testicular dysfunction, with mean maximal vein diameter increases to 5.0 mm (grade I), 5.8 mm (grade II), and 6.6 mm (grade III) compared to 2.5 mm in normal testicular units 4

Varicoceles are present in approximately 15% of normal males but 35-40% of men presenting with infertility, as reported by the European Urology association 4

The American Urological Association recommends that routine use of ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of subclinical varicoceles does not improve semen parameters or fertility rates, in patients with varicoceles and no fertility concerns 5

The presence of reflux on ultrasound alone does not determine clinical significance, and varicoceles affect 15% of normal males, with most never requiring treatment, according to the Journal of Urology 5
Higher grade varicoceles (Grade III, >6mm) are associated with worse semen parameters and testicular dysfunction, in the general population, although the exact mechanism is not well understood 5