Varicocèle | Clinique Omicron Québec

Clinical classification (Dubin and Amelar)

• Grade I (subclinical or palpable only on Valsalva maneuver): not visible + palpable only during Valsalva effort (increase in abdominal pressure) → detectable only on Doppler ultrasound in subclinical forms
• Grade II (palpable without Valsalva): easily palpated on bimanual palpation of the spermatic cord without effort + not visible → venous dilatations felt like a «bag of worms» above the testicle
• Grade III (visible) : visible on inspection + palpable + often symptomatic (pain + scrotal heaviness) → venous dilatations visible through the scrotal skin

Clinical presentation

• Often asymptomatic: chance discovery during a physical examination or infertility work-up + no functional symptoms in most cases (especially grades I and II)
• Scrotal pain: dull pain + scrotal heaviness + sensation of heaviness + aggravated by prolonged standing + physical exertion + heat + relieved by dorsal recumbency + characteristically absent on waking (improved after lying down overnight)
• Testicular atrophy: reduction in volume of the left testicle (or right testicle if bilateral varicocele) → important sign in adolescents (cessation of testicular growth + indication for surgery even without infertility) → measurement by orchidometry (Prader orchidometer) or ultrasonography
• Male infertility: oligospermia (reduced concentration) + asthenospermia (reduced mobility) + teratospermia (abnormal forms) → qualitative and quantitative alteration of sperm + mechanisms: testicular hyperthermia + oxidative stress + hypoxia + reflux of adrenal metabolites + altered spermatogenesis
• Red flag - isolated or sudden right varicocele (>40 years) : requires urgent abdominal imaging (ultrasound + or CT scan) to exclude a retroperitoneal mass (kidney cancer + lymphoma) compressing the vena cava or renal vein → secondary varicocele

Diagnosis

• Clinical examination in standing position (essential) : bimanual palpation of standing spermatic cord + Valsalva maneuver → sensation of «bag of worms» over left testicle + comparative measurement of bilateral testicular volume → a varicocele is NOT palpable in decubitus position (it disappears when reflux ceases in supine position)
• Scrotal Doppler ultrasound : reference examination + confirms diagnosis + quantifies reflux + measures vein diameter (varicocele if >3 mm at rest + or reflux at Valsalva) + measures testicular volume + detects subclinical varicocele + evaluates testicles (looks for associated testicular tumour)
• Spermogram (sperm analysis according to WHO 2021 criteria) : essential in any man with varicocele and desire for paternity + or with partner presenting infertility → concentration + total and progressive mobility + morphology (strict Kruger criteria) + volume + pH + leukocytes
• Hormone balance : FSH + LH + total testosterone + prolactin → if testicular atrophy is severe + or if spermogram is severely altered

Therapeutic indications

• Well-established indications for treatment : clinical varicocele (palpable) + abnormal spermogram + couple infertile for ≥ 12 months + absence of other uncorrectable cause of infertility in partner + clinical varicocele + testicular atrophy in adolescent (even without fertility work-up)
• Subclinical varicocele (detectable only on ultrasound) : treatment not recommended - no proven benefit on fertility
• Asymptomatic varicocele with normal spermogram: monitoring + no systematic treatment
• Disabling scrotal pain : indication for treatment, even without infertility, if significant pain despite conservative measures (NSAIDs + jockstrap)

Treatment options

• Microsurgical sub-inguinal varicocelectomy (gold standard): microsurgical surgical ligation of spermatic veins under optical guidance (microscope) + via inguinal or subinguinal approach + preservation of lymphatics (reduced risk of post-operative hydrocele) + testicular arteries + and nerves → success rate (spermogram improvement): 60-80 % + post-treatment natural pregnancy rate: 35-45 % → reference technique with the best results and lowest morbidity
• Percutaneous embolization (interventional radiology) : retrograde + or antegrade catheterization of spermatic veins + occlusion with coils or sclerosant → ambulatory + less invasive + success rate slightly lower than surgery (50-70 %) + more frequent recurrence + useful if post-surgical recurrence or unfavorable anatomy
• Laparoscopic ligation (Palomo): laparoscopic high spermatic vein ligation + technically easier + but higher post-operative hydrocele rate (15-20 %) as lymphatics are often ligated
• Fertility results : improved sperm count in 60-80 % of cases at 3-6 months post-treatment + increased natural conception rates + improved IVF/ICSI results if treatment is performed prior to MAP

Consult at Clinique Omicron

Clinique Omicron's specialized physicians and nurse practitioners (IPS) examine the scrotum in the standing position with Valsalva maneuver to detect varicocele, prescribe confirmatory scrotal Doppler ultrasound, prescribe a spermogram in accordance with WHO 2021 criteria for the assessment of male infertility, refer to urology for microsurgical varicocelectomy if the indications are met, and look for a secondary cause (renal tumor) in the case of any isolated or late-onset right-sided varicocele. Consultations are available at several points of service in Quebec, as well as via telemedicine. To book an appointment, visit cliniqueomicron.ca.

The contents of this page are provided for information purposes only and do not replace the advice of a physician or urologist. Subclinical varicocele detectable only on ultrasound is not an indication for treatment. Isolated right-sided varicocele or sudden onset after the age of 40 should prompt the urgent exclusion of a retroperitoneal mass (kidney cancer).