Varicocele Treatment & Management

A varicocele is an anatomic abnormality that can impair sperm production and function. No effective medical treatments for varicoceles have been identified. Some evidence supports the use of dietary supplements, including vitamins A, E, C, and B complex; glutathione; pantothenic acid; coenzyme Q10; carnitine; and micronutrients such as zinc, selenium, and copper. These may increase levels of antioxidant enzymes and decrease levels of inflammatory markers. ^{[22, 23]}

In elderly men, impairment of Leydig cell function by varicocele can compound the decrease in testosterone production that occurs with aging, resulting in hypogonadism. Testosterone replacement therapy is an option in these patients, who are unlikely to be concerrned with fertility. Nevertheless, while the possibility of avoiding surgery may appeal to these patients, with education about their options they may conclude that a one-time low-risk microsurgery is preferable to lifelong testosterone therapy with laboratory monitoring. ^[24]

The primary form of treatment for varicoceles is surgery. Because of the potential to cause significant testicular damage, evaluate the varicocele during the physical examination. The presence of a varicocele does not in itself mean surgical correction is necessary.

The ultimate goals of varicocele repair should include occlusion of the offending varicosity, preservation of arterial flow to the testis, and minimization of patient discomfort and morbidity. Viable options for repair include radiographic obliteration and surgical repair of various approaches. The efficacy of the myriad techniques is nearly equivalent. Therefore, special attention must be paid to the morbidity of the individual procedure and the expertise of the operating surgeon.

Results from a prospective, randomized controlled trial from Saudi Arabia compared subinguinal microsurgical varicocele repair to observation. ^[25] Inclusion criteria included infertility lasting 1 year or longer, demonstration of a palpable varicocele, and presence of at least one impaired semen parameter (sperm concentration < 20 million/mL, progressive motility < 50%, or normal morphology < 30%). A total of 145 participants had follow-up within 1 year; spontaneous pregnancy was achieved in 13.9% of controls compared with 32.9% of treated men (odds ratio, 3.04). In treated men, the mean of all semen parameters significantly improved in follow-up compared with baseline (p< 0.0001). This study provided an evidence-based endorsement of the superiority of varicocelectomy over observation in infertile men with palpable varicoceles and impaired semen quality.

Surgical techniques for varicocele repair include retroperitoneal, laparoscopic, inguinal, and subinguinal. The microsurgical subinguinal approach is the gold standard. ^{[26, 27]} A meta-analysis found that although microsurgical varicocelectomy involves a longer operative time, it has a lower incidence of postoperative complications and recurrence than laparoscopic and open varicocelectomies and a shorter time to return to work, as well as a greater increase in postoperative sperm concentration, better improvement in postoperative sperm motility, and a higher pregnancy rate. ^[28]

Microsurgical repair of varicocele may improve the patient's erectile and ejaculatory function, along with raising  testosterone levels. In a review by Najari et al of 17 patients with infertility and 13 with symptomatic varicocele associated with hypogonadism, most of whom had bilateral varicoceles and left grade III varicoceles, 15 patients (44%) reported improvement in their erectile function and 18 (53%) reported improvement in ejaculatory function. Serum testosterone levels rose 136.0 ±201.3 ng/dL. ^[29]

In patients with a left clinical varicocele accompanied by a right subclinical varicocele, the choice of unilateral versus bilateral varicocelectomy has been controversial. However, studies have shown superior improvement in sperm parameters and spontaneous pregnancy rates with bilateral varicocelectomy in these patients. ^{[30, 31]}

Perform varicocele surgery in an outpatient setting using one of various anesthetics (eg, general, regional, local). A general anesthetic provides maximal patient comfort.

The three most common surgical approaches used to correct a scrotal varicocele are as follows:

• Inguinal (groin)
• Retroperitoneal (abdominal)
• Infrainguinal/subinguinal (below the groin)

With all three approaches, all abnormal veins are tied permanently to prevent continued abnormal blood flow. Avoidance of the vas deferens and the testicular artery during the surgery is critical. The inguinal approach is depicted below.

The inguinal and subinguinal approaches are those most commonly used by the vast majority of adult urologists and infertility specialists. The familiar anatomy, low morbidity, and high efficacy make these approaches almost ideal. Inguinal ligation is achieved by incising the inguinal canal down to the external inguinal ring. After cord isolation, the testicular artery is preserved and the veins of the cord are ligated and divided.

The subinguinal approach is performed in a similar fashion, but access is achieved through an incision at or near the pubic tubercle, which obviates the opening of the external oblique aponeurosis. The advantages of subinguinal varicocele ligation, especially with use of magnification, include decreased pain and easier access to the spermatic cord, especially in obese men and those with a history of inguinal surgery. However, at this level, a greater number of veins are present, especially periarterial anastomosing veins, which makes subinguinal ligation technically challenging.

The use of the microsurgical technique has advanced the surgical treatment of this disorder by allowing optimal visualization. While the approach to cord isolation is no different, the 6-25X magnification facilitates the identification of small anastomosing veins that might otherwise be missed. Furthermore, the risk of testicular ischemia and testis atrophy due to inadvertent ligation of the testicular artery is greatly reduced with this improved visualization. This risk of arterial ligation can be further reduced by using a mini-Doppler ultrasound probe (Vascular Technology, Inc. [VTI] 20-MHz microvascular Doppler) with the use of a topical vasodilator.

The retroperitoneal approach offers great proximal control of the spermatic vein near its insertion at the renal vein, and this approach may be accomplished laparoscopically. Although this approach to varicocele ablation remains popular among pediatric urologists, it has the following potential drawbacks:

• A high recurrence rate (nearly 15%), due to inguinal and retroperitoneal collateral veins
• Failure to ligate fine periarterial veins when the testicular artery is preserved
• Inability to preserve lymphatics
• Potential hydrocele formation when the artery and vein are ligated en bloc

Percutaneous embolization represents the least invasive means of varicocele repair. ^[27] The internal spermatic vein is accessed primarily via cannulation of the femoral vein through a retrograde approach with subsequent balloon and/or coil occlusion of the varicocele. The advantages of percutaneous embolization include preservation of the testicular artery and the relatively noninvasive nature of the technique. However, the percutaneous approach can be fraught with troublesome access to the vein, and postoperative complications such as contrast allergies, arterial injury, thrombophlebitis, and coil migration are uncommon but tangible risks. This approach is often reserved for recurrent varicoceles after open surgical repair.

In antegrade sclerotherapy for varicocele, an incision is made at the scrotal root level, a vein in the pampiniform plexus is selected and cannulated, and a sclerosing agent is mixed with air to make a foam and immediately injected into the spermatic vein under fluoroscopic guidance. Although this technique has been criticized because of the radiation exposure involved, Bebi et al argue that this concern may reflect the older technology used in early studies; in contrast, their study in 251 patients determined that with current techniques, the median effective dose was 0.19 mSv millisieverts, which is comparable to that received in common diagnostic procedures, such as abdominal x-rays. ^[32]

A prospective study by Chung et al that compared scrotal antegrade sclerotherapy with laparoscopic varicocele surgery in 113 patients concluded that both procedures are safe and effective for treatment of adolescent varicocele, with a significant positive effect on testicular catch-up growth. No statistically significant differences in clinical recurrences between the 2 groups was found at 12-month follow-up; however, postoperative hydrocele occurred in seven patients in the laparoscopic surgery group but in none of the scrotal antegrade sclerotherapy group. ^[33]

A systematic review and meta-analysis by Fabiani et al of complications, and recurrence rate of varicocele treatment by comparing the surgical ligature versus sclero-embolization techniques in children, adolescents and adults concluded that neither approach was superior; the incidence of postoperative hydrocele was significantly higher in the surgical ligation group, but the incidence of postoperative orchiepididymitis was significantly higher in sclero-embolization group. ^[34]

Shibata et al reported that intraoperative indocyanine green angiography (ICGA), which is regularly used in microsurgical neurosurgery, can facilitate microsurgical subinguinal varicocelectomy by enabling the visualization and identification of the testicular arteries in the spermatic cord. After the exposure of the spermatic cord blood vessels, ICG was injected intravenously under a surgical microscope and the resulting infrared fluorescence allowed surgeons to safely and quickly ligate the spermatic veins. ^[35]

Patient instructions

See the list below:

• Varicocele surgery is usually performed in an outpatient setting (ie, day-surgery unit). Patients may return to normal nonstrenuous activities (eg, work) after 2 days.

• All outer dressings are removed 48 hours after surgery. The small strips of tape (Steri-Strips) are left in place for 7-10 days before removal.

• Inform patients that bathing or showering is permitted 48 hours after surgery.

• A normal, well-balanced diet can be resumed when patients return home. Advise patients to start with fluids and gradually return to solid foods.

• Prescribe pain medication and advise patients to take as directed. After 2 days, patients may take nonprescription acetaminophen (eg, Tylenol) or ibuprofen (eg, Advil, Motrin) to relieve discomfort.

• Patients can engage in normal, nonstrenuous activity when they feel up to it. If activity causes discomfort, it should be discontinued. Patients can resume more strenuous activities (eg, weightlifting, jogging) after 2 weeks.

• Advise patients to refrain from intercourse for 1 week.

Common discomforts and symptoms that do not require medical attention

Patients may experience some postoperative discomfort. Complications are rare. Common discomforts or symptoms do not require a doctor's attention and may include the following:

• Minor bruising and slight discoloration may appear around the groin incisions but are self-limited.

• The sensation of hardness around and beneath the incision site resolves in approximately 3 weeks.

• The slight redness and tenderness around the incision from the normal healing process resolves in a few days.

• A very small amount of thin, clear, pinkish fluid drains from the incision for a few days after the procedure. Advise patients to keep the area clean and dry.

• A sore throat, headache, nausea, constipation, and general body ache occur because of the surgical procedure and anesthetic. Advise patients that these problems resolve within 24 hours.

Postoperative complications that require prompt medical attention

If wounds become infected (usually 3-5 d after surgery), antibiotics may be necessary. Infected wounds can become warm, swollen, red, and painful, with significant drainage from the incision site, and patients may develop fever.

Hematomas may form. Extreme discoloration around the abdominal incisions results from bleeding underneath the skin, which causes throbbing pain and bulging wounds.

Check the patient's semen 3-4 months after surgery. Because spermatogenesis requires approximately 72 days, any effects from the varicocele repair on semen analysis results are delayed.

Patient instructions

See the list below:

• The patient returns to the clinical office for a wound evaluation in approximately 7-10 days.

• Schedule a follow-up examination for a wound check and varicocele examination for 8 weeks after surgery.

• Schedule a semen analysis and consultation for 4 months after surgery. At this time, the timing of subsequent appointments can be discussed.

For patient education information, see Varicocele.

The prevalence of adverse effects following varicocele repair is remarkably low. Hydrocele or increased fluid around the testicles occurs in 2-5% of patients. Successful surgery often increases conception rates in infertile couples. The overall recurrence rate for varicoceles has been reported as high as 10%.

The long-term occurrence of hydroceles and varicocele recurrence was analyzed in a study comparing 67 patients who received lymphatic-sparing laparoscopic varicocelectomy with 30 patients who received a plain laparoscopic varicocelectomy. The risk of hydrocele formation was significantly less in lymphatic-sparing group (4.5% vs. 43.3%). In addition, none of the patients with hydrocele formation in the lymphatic-sparing group required a hydrocelectomy, compared with 31% in the plain laparoscopic group. ^[36]

The varicocele recurrence rate was higher in the lymphatic-sparing group (6% vs 3.3%) but when the artery was not preserved, the rate in the lymphatic-sparing group fell to 1.3%. The success and complication rates of lymphatic-sparing, non–artery preserving, laparoscopic varicocelectomy were comparable with those of subinguinal microsurgical varicocelectomy. ^[36]

Injury to the testicular artery has been reported in 0.9% of microsurgical varicocele repairs. ^[37] This incidence may be higher when optical magnification is not used for varicocele repair. Because the testis typically has additional arterial supplies from the vasal and cremasteric arteries, testicular atrophy is uncommon (5%) after division of the testicular artery. Smaller atrophic testes may be at greater risk for accidental testicular artery injury because of the smaller size of the artery in these cases.

In a patient in whom a varicocele is first identified during a vasectomy reversal, varicocelectomy at the time of the vasectomy reversal is controversial. Delaying the varicocelectomy preserves some venous return in these patients and avoids possible injury to the testicular artery. Consider varicocele repair 6 months later, after new vascular channels form.

Following varicocelectomy, approximately 66-70% of patients have improved bulk semen parameters, and 40-60% of patients have increased conception rates. Because human spermatogenesis takes approximately 72 days, the first improvements in semen analysis results are typically not apparent until 3-4 months after surgery.

While many of the published studies are retrospective, a randomized, prospective, controlled study by Magdar and associates (1995) confirmed that varicocelectomy is an effective treatment for male subfertility. Magdar et al studied male counterparts in couples in 2 subject groups, groups A and B. Group A (20 male subjects with varicoceles) was studied for 1 year, and only 2 (10%) men initiated a pregnancy. Male subjects who could not initiate a pregnancy then underwent varicocele repair; within 2 years, 12 (66%) were successful in initiating a pregnancy. ^[38]

Meanwhile, 25 male subjects in group B underwent immediate varicocele repair. Within the first year, 15 (60%) initiated a pregnancy. After 3 years, an additional 4 (16%) subjects achieved pregnancy. Semen parameters improved in all subjects who underwent varicocele repair, regardless of pregnancy occurrence. Semen parameters were unchanged among group A subjects during their 1 year of observation. This important study concluded that varicoceles are associated with reduced fertility and impaired testicular function, while repair improves sperm parameters and fertility rates. ^[38]

In addition, Vasquez-Levin et al (1997) demonstrated that varicocele repair benefits sperm morphology, even when evaluated using so-called strict criteria. ^[39]

Agarwal et al conducted a systematic review and meta-analysis of changes in conventional semen parameters after varicocele repair in 1424 infertile men with clinical varicocele, versus changes in a control group of 996 men over the same period. Compared with the control group, patients who underwent varicocele repair showed significant improvements in sperm concentration (P < 0.001), total sperm count (P < 0.05), progressive sperm motility (P < 0.01), total sperm motility (P=0.04), and normal sperm morphology (P < 0.05). ^[40]

Evers and Collins performed a meta-analysis of 7 randomized controlled trials. Because overall pregnancy rates were 21.7% in operated patients and 19.3% (pNS) in control patients, they concluded that varicocele repair did not improve natural pregnancy rates. ^[41] The concerns with this meta-analysis are that inclusion criteria regarding severity of impairment in semen parameters were not uniform, the varicocele diagnostic criteria and grading were inconsistent, and female factors were not mentioned in their overall analysis.

The persistent or recurrent varicocele can be repaired microsurgically with significant improvements in sperm concentration, percent motility, and total motile sperm per ejaculate. In addition, as reported by Grober et al, a beneficial effect on serum testosterone levels, testicular volume, and pregnancy rates can be observed. ^[42]

The optimal approach to varicocele ligation has not been proven in evidence-based studies. However, based on available experience and reports, the authors recommend varicocele ligation be performed through an inguinal or subinguinal approach with the use of an operating microscope and hand-held microvascular Doppler ultrasound probe.

In 1992, researchers introduced a new micromanipulation technique known as intracytoplasmic sperm injection (ICSI). With ICSI, surgeons inject a single spermatozoon into an oocyte to initiate fertilization and, eventually, a pregnancy. With the success of this technique, some researchers question the need for varicocele repair.

Conversely, a cost-analysis study by Schlegel shows the significant cost advantage of varicocele repair over ICSI. ^[43] In addition, varicocele repair has the potential for improving the male factor, rather than using unknown sperm. ICSI also involves in vitro fertilization (IVF), which carries some risk for the female who donates surgically removed eggs. Finally, varicocele repair can also increase testosterone levels, benefiting long-term male health. ^[44]

Another current topic focuses on the benefit of varicocele repair in men who are azoospermic or severely oligospermic. Although numerous studies indicate that varicocele repair can improve spermatogenesis in up to one third of azoospermic men, the initiation of spontaneous pregnancy is highly unusual in this population. ^[45] The remaining two thirds eventually require testicular sperm extraction and IVF-ICSI, even after varicocele repair. Couples must therefore be counseled realistically regarding the benefit of varicocelectomy in this setting.

Other concerns focus on the benefit of varicocele repair in infertile men with poor semen quality who have only ultrasound evidence of a varicocele. While opinions differ about the value of repairing subclinical varicoceles in infertile men, most experts do not recommend it.