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
|
adolescent
|
sub-clinical or grade I varicocele
1st line – 

reassurance

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

1st line – observation

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

observation

Observation with serial examinations is best suited for an adolescent with symmetrical 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.[1]

Patients and parent or carer should be counselled about the potential for reduced fertility in later life if the varicocele is not treated.[54]

1st line – varicocele repair

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ACUTE
|
adolescent
|
grade II or III varicocele: asymmetrical (>2 cm³ or >20% difference)
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 testes). Significant pain is rare, and is an indication for treatment.[1][56]

Varicocele repair techniques include: embolisation; antegrade or retrograde sclerotherapy; and ligation (open retroperitoneal, inguinal, laparoscopic, or microsurgical subinguinal).[32]​ Varicocele treatment will fully eliminate more than 90% of varicoceles (98% if microscopic subinguinal approach is used).[31][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 it is considered the gold standard approach in adults, further research is required to confirm the role of the microsurgical subinguinal approach in adolescents.[24]

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]

adult

1st line – reassurance

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ACUTE
|
adult
|
sub-clinical 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.[31]

For men with unexplained infertility, abnormal semen parameters, and clinically palpable varicoceles, varicocele repair is recommended.[32][62]

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.[40]​ 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.[32][62]

An improvement in semen parameters can be seen with repair of any clinically palpable varicocele.[34]​​[46]​​[49]​​​ The degree of improvement, however, likely depends on the size of the varicocele.​​​[61]

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.[57][58][59]

In the UK, the National Institute for Health and Care Excellence recommends against offering surgical varicocele repair as a fertility treatment.[60]

Although previously thought to be an uncommon cause of hypogonadism, varicocele has been increasingly linked to Leydig cell dysfunction.[30]​ For men with palpable varicoceles and hypogonadism, surgical repair may improve testosterone levels.[63]​ Varicocelectomy can be offered to these patients, although they should be counselled on the lack of robust, prospective, randomised studies.[32]

Repair techniques include: embolisation; antegrade or retrograde sclerotherapy; and ligation (open retroperitoneal, inguinal, laparoscopic, or microsurgical subinguinal).[32]​ Varicocele treatment will fully eliminate more than 90% of varicoceles (98% if microscopic subinguinal approach is used).[31][47]​

Microsurgical subinguinal varicocele ligation has lower rates of complications and recurrence compared with percutaneous or open nonmicrosurgical approaches; it is also more likely than other surgical techniques to improve pregnancy rates.[34][49][50]​​​

Choice of repair 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] 

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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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