Painful varicocele in an infertile man

• Published in: Canadian Medical Association journal (CMAJ) Vol. 185; no. 4; pp. 321 - 322
• Main Authors: Forster, James A, Biyani, C Shekhar
• Format: Journal Article
• Language: English
• Published: Canada CMA Joule Inc 05.03.2013; CMA Impact, Inc; Canadian Medical Association
• Subjects: Adult; Analysis; Care and treatment; Complications and side effects; Diagnosis; Humans; Infertility, Male; Infertility, Male - etiology; Male; Mens health; Pain - etiology; Practice; Reproductive system; Risk factors; Systematic review; Testis - blood supply; Varicocele; Varicose Veins - complications; Varicose Veins - diagnosis; Vein & artery diseases; Canada
• ISSN: 0820-3946; 1488-2329
• DOI: 10.1503/cmaj.121445

This patient should be referred nonurgently, ideally to a urologist with an interest in andrology or infertility. Whereas most varicoceles can be managed with assessment and reassurance, referral to a urologist is suggested for adults with infertility, pain or discomfort, or a suspicion of malignant disease. Children with a varicocele should be referred, as well as adolescents with bilateral varicoceles, diminished testicular growth or a large varicocele causing emotional upset.5,6 This is a contentious matter, because of differing conclusions in the literature as to whether vari - cocele treatment simply improves semen pa - rameters or actually increases pregnancy rates. Although the Canadian Urological Association does not cover this subject in its guidelines, the American Urological Association recommends offering repair of grades 1-3 varicoceles for men with abnormal semen analysis results (whether or not he is attempting conception) and recommends repair in adolescents with a varicocele associated with reduced ipsilateral testicular size.5 The European Association of Urology recommends that varicocele repair be considered in the case of grades 1-3 varicoceles with oligo spermia and at least 2 years of otherwise unexplained infertility, and it is recommended for adolescents with progressive failure of testicular development. 6 A 2009 Cochrane review found no evidence that treatment of varicocele improves conception rates; however, this review has been criticized because men with normal semen analysis and with subclinical varicocele were included.8 The most recent meta-analysis reported a nonsignificant improvement in pregnancy rates with treatment of varicocele with a combined odds ratio of 2.23 (95% confidence interval 0.86-5.78, p = 0.09), suggesting further trials are needed to answer this important clinical question.9