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Continuing Education Activity

A varicocele is a common medical condition characterized by abnormal dilation and enlargement of the scrotal venous pampiniform plexus, which drains blood from each testicle. The result is often a complex network of swollen vessels. Varicoceles are classified as small, medium, and large. While many individuals with varicoceles may remain asymptomatic, these varicose-like veins can lead to various issues, including discomfort, testicular atrophy, and impaired fertility. Varicoceles are clinically significant because they are the most commonly identified cause of abnormal semen analysis, low sperm count, decreased sperm motility, and abnormal sperm morphology. Varicoceles are a prevalent concern among men, particularly in the reproductive age group, and understanding this condition is essential for healthcare professionals. This activity examines when this condition should be considered in the differential diagnosis, how to evaluate it properly, and the indications for possible surgical correction. This activity also highlights the role of the interprofessional team in caring for patients with this condition.


  • Identify the etiology of varicoceles.

  • Screen male patients at risk for varicocele, such as adolescents with scrotal pain, infertility concerns, or abnormal testicular findings, using appropriate diagnostic tests and criteria.

  • Implement evidence-based guidelines and surgical techniques for the treatment of varicocele, considering patient age, symptoms, and reproductive goals.

  • Collaborate with an interprofessional team to provide comprehensive care and improve outcomes for patients with varicoceles.


A varicocele is an abnormal dilation and enlargement of the scrotal venous pampiniform plexus, which drains blood from each testicle. While usually painless, varicoceles are clinically significant because they are the most commonly identified cause of abnormal semen analysis, low sperm count, decreased sperm motility, and abnormal sperm morphology.[1][2][3] They can also affect testicular growth.[4]

The testicular veins originate in the testicle and form the pampiniform plexus. Venous blood then travels up through the inguinal canal as part of the spermatic cord, forms the internal spermatic or testicular vein, and terminates in the abdomen. The right internal spermatic vein empties directly into the low-pressure inferior vena cava, while on the left side, it joins with the relatively high-pressure left renal vein, which can impede left testicular venous drainage. This anatomy explains why the overwhelming majority of clinically detectable varicoceles are on the left side.[5]

Varicoceles occur in approximately 15% to 20% of all males but are found in about 40% of infertile males.[5] It is unclear exactly how a varicocele impairs the production, structure, and function of sperm, although there are several theories. The association between clinically significant varicoceles and male infertility is undeniable.[6] This association was first noted in the late 1800s by Barfield, a British surgeon, and was subsequently confirmed by others in the early 1900s.

There is clear and compelling evidence from multiple studies and meta-analyses that surgical repair of clinically significant varicoceles in infertile males with abnormal semen parameters can significantly improve sperm counts, motility, morphology, and pregnancy rates.[3][6][7][8][9][10][11][12][13][14][15][16][17]

Repairs of clinically apparent (large or medium-sized) varicoceles in adolescent males may normalize hormonal values, testis size, and sperm characteristics.[4][7][18][19][20][21][22]


Varicoceles are thought to develop from a backup of venous blood flow in the internal spermatic vein that causes venous engorgement, which is clinically detectable on scrotal examination.[23][24] Alternate venous drainage from the testicle includes the cremasteric and deferential veins.

Varicoceles are far more common (80% to 90%) in the left testicle. If a left varicocele is identified, there is a 30% to 40% probability it is a bilateral condition.[25]

There are 3 theories as to the anatomical cause: [5][26][27][28]

  • Failure of the antireflux valve where the internal spermatic vein joins the left renal vein. This failure causes reflux and retrograde flow in the testicular vein.                                                                                                                         
  • Angulation at the juncture of the left internal spermatic vein and the left renal vein.                                            
  • The "Nutcracker" effect which occurs when:
    • The left internal spermatic vein gets caught between the superior mesenteric artery and the aorta. This entrapment causes venous compression and spermatic vein obstruction.
    • There is 50% or more compression of the left renal vein between the abdominal aorta and the superior mesenteric artery. This causes increased venous pressure in the left renal vein, resulting in left spermatic vein obstruction.
    • See our companion StatPearls reference article on "Nutcracker Syndrome."[27]

Rare causes of varicoceles include deep vein thrombosis, renal arteriovenous malformations, and thrombosis of the pampiniform plexus.

Tobacco smoking and mutations in the gene expressing glutathione S-transferase Mu 1 increase the risk of male infertility. 

When a varicocele contributes to an abnormal semen analysis, it typically causes a "stress pattern" on microscopic semen examination. This pattern consists of a low sperm count, poor motility, and an increase in the percentage of abnormal sperm.[6]


Approximately 15% to 20% of all adult males will have a varicocele, and up to 40% percent of men evaluated for infertility will also have a varicocele.[24][29][30]

During the workup of infertile couples, there appears to be a significant delay in the male evaluation for possible varicoceles. At 1 academic center, 18% of the infertile men referred after various costly assisted reproductive procedures were ultimately found to have varicoceles and qualified for a simple varicocelectomy. The female partner had no identifiable negative fertility findings in 70% of these infertile couples.[31]


Usually, the primary concern with a varicocele is infertility. Most men with varicoceles are fertile, but others have sperm compromised in function, morphology, numbers, and/or movement. Researchers theorize that the sperm may be damaged due to excess heat caused by increased oxidative stress on the sperm from blood pooling, causing reduced oxygenation, direct hydrostatic pressure injury effects on the testis, toxin formation, hypoxia, autoimmunity, or an increase in adrenal steroids concentration being delivered to the testicle since the adrenal veins empty into the left renal vein almost directly opposite the entry of the internal spermatic vein.[5]

Varicoceles may also reduce spermatic DNA integrity (fragmentation), increase oxidative stress, and negatively affect other aspects of spermatic function.[32]

The most accepted theory is that increased blood flow leads to higher intratesticular temperature, the main cause of impaired sperm in varicoceles.[33]

While untreated varicoceles may progress, they infrequently cause pain, although this is reported in 2% to 10% of varicocele patients.[2][34] Suggested mechanisms for such pain include increased testicular temperatures, higher venous pressure, oxidative stress, hormonal imbalances, reflux of toxic metabolites from the kidneys or adrenals, hypoxia, or possible stretching of nerve fibers in the spermatic cords from the dilated varicocele complex.[2] Orchialgia associated with varicoceles is typically described as aching, dull, or throbbing but rarely can be acute, sharp, or stabbing.[35]

It is thought that large varicoceles may eventually cause testicular failure, ultimately resulting in lower hormonal production, oligospermia, and testicular atrophy. Varicoceles can also decrease sperm nuclear DNA integrity, which has been linked to reduced sperm motility, viability, counts, and abnormal morphology.[36]

Varicoceles can cause a reduction in testosterone production by the Leydig cells in the testes, particularly in older men.[37][38][39][40] Varicocelectomy improves the serum testosterone level in >80% of patients, with a mean increase between 100 ng/mL and 140 ng/mL. The greatest increase in testosterone was found in hypogonadal (testosterone <300 ng/mL) men. This finding and other data suggest that varicocelectomy may be a viable surgical option to permanently treat low testosterone levels in older hypogonadal men with significant varicoceles.[38][39][40][41][42]

History and Physical

Most often, varicoceles are found during a routine physical examination or an infertility workup. Varicoceles are usually asymptomatic, but 2% to 10% of patients will complain of pain.[2][34] The discomfort is usually described as an aching, dull, or throbbing pain, and only rarely is it characterized as sharp, acute, or stabbing.[2] Patients may sometimes complain of heaviness in the scrotum.

Varicoceles present as soft lumps above the testicle, usually on the left side of the scrotum. The patient may describe a "bag of worms" if the varicocele is large enough. Right-sided and bilateral varicoceles may also occur.

Large varicoceles are easily identified on simple inspection alone and will show the typical "bag of worms" appearance. Medium varicoceles would describe those that are identifiable by palpation or physical examination without any bearing down by the patient. Small varicoceles are defined as those that can be identified only during a strong Valsalva maneuver (bearing down). Subclinical varicoceles cannot be detected clinically but are only identified on ultrasound imaging.


After the physical exam, the varicocele can be confirmed with high-resolution color-flow Doppler ultrasound, which will show dilation of the vessels of the pampiniform plexus, typically 3 mm in diameter or more.[43][44][45] This is most useful in equivocal or borderline cases. Routine imaging is not necessary for clinically significant varicoceles, and venography, in particular, is rarely needed or recommended but can be of some use for recurrent or treatment-resistant varicoceles.[46][47][48]

Thermal imaging is another noninvasive, painless, and non-contact technique for evaluating and confirming a possible varicocele.[49][50][51][52]

Testicular strain elastography is being studied for its potential usefulness in identifying varicocele patients who would benefit from treatment.[53][54][55][56]

Traditionally, it was always recommended to consider the possibility of renal cell carcinoma tumor extending into the vena cava as a possible cause of any isolated right-sided varicocele. A right-sided renal vein tumor thrombus can extend into the vena cava, causing a venous blockage resulting in spermatic vein obstruction and a right-sided varicocele. Computed tomography (CT) imaging is recommended if this is considered likely or possible.[57][58] A significant unilateral right-sided varicocele, sudden onset of the varicocele, or if the varicocele is not reducible are considered suspicious characteristics for retroperitoneal pathology.

Recently, this practice has been reevaluated as the incidence of such malignancies is quite low and insufficient to justify routine imaging.[58][59][60] It has been suggested that a quick right renal ultrasound performed at the time of scrotal ultrasonography would be a very cost-efficient way to identify any clinically significant retroperitoneal pathology, right renal masses, vena cava obstructions, and right renal vein thrombi without the cost, anxiety or radiation exposure of a CT scan.[60][61][62][63]

Treatment / Management

There are no effective medical treatments for varicoceles. If a varicocele is causing pain or discomfort, the use of analgesics and scrotal support can be used initially. When a varicocele is treated surgically, it is usually an outpatient procedure. The most common approaches are retroperitoneal abdominal laparoscopic, infrainguinal, subinguinal below the groin, or intrascrotal. Antegrade scrotal sclerotherapy may also be performed.[64][65][66] Avoiding the vas deferens and the testicular artery during surgery is mandatory regardless of approach.[67][68][69][70]

Percutaneous embolization can also be performed, usually by interventional radiology.[64][71] This involves passing a catheter from the femoral vein, up the vena cava, laterally into the left renal vein, and then inferiorly into the spermatic vein.[64][65][71] An 89% success rate with this technique has been reported. While less invasive than open surgery, it can be technically challenging and is generally less cost-effective.[72] Percutaneous endovascular embolization is commonly used for recurrent varicoceles as an alternative to repeat open surgery.

Some pediatric urologists prefer a retroperitoneal, laparoscopic approach, which allows for control of the spermatic vein very near its insertion into a left renal vein. However, this technique has a relatively high recurrence rate (15%).

Open surgical and percutaneous endovascular embolization approaches to varicocele treatment have roughly equivalent success and complication rates, as well as antegrade scrotal sclerotherapy. Still, pregnancy rates appear to be higher with surgical therapy.[72][73][74][75]

Microsurgical techniques allow for the identification of small anastomosing vessels that might otherwise be missed. It also permits better identification of the testicular artery, thereby minimizing its inadvertent injury.[76][77][78] The procedure can be facilitated and even safer by applying a topical vasodilator and utilizing a mini-Doppler 20 MHz microvascular ultrasound probe.

Overall, the microsurgical subinguinal varicocelectomy is considered the preferred corrective procedure for the condition as it has a lower rate of recurrences, fewer complications, a quicker return to work, and demonstrates a greater improvement in sperm counts and motility as well as a higher pregnancy rate than alternative procedures.[12][79][80][81]

The indications to remove a varicocele include relief of pain, reducing the risk of testicular atrophy, and treating or preventing infertility. Candidates for repair should meet the following conditions: [7][35]

  • Abnormal semen parameters ("stress pattern") in infertile men
  • Male infertility with normal fertility in females (although female infertility factors are not a contraindication for varicocele surgery in the male)
  • Pain or discomfort related to the varicocele
  • Palpable or clinically apparent varicocele
  • When a clinically significant, high-grade varicocele is associated with failure of testicular development and growth in adolescent males (>20% difference in testis size)

The European Association of Urology guidelines on male infertility are similar but suggest that in addition to a clinically significant varicocele, there should also be evidence of oligozoospermia or otherwise unexplained fertility of 2 years or longer to justify surgery. They do not recommend surgery in men with normal semen parameters or subclinical varicoceles.[8]

Very large varicoceles may also be repaired; however, in the absence of pain, testicular atrophy, or abnormal semen analysis, this indication remains controversial. 

If bilateral varicoceles are found, both should be repaired at the time of surgery.[82] If there is a clinically significant left varicocele but only a subclinical right varicocele, there is evidence that repairing both may ultimately be beneficial in producing a pregnancy.[83][84] Following surgery, approximately 70% of patients have improved semen parameters, and 40% to 60% of couples have improved conception rates. This improvement in semen quality will typically become noticeable at approximately 3 to 4 months after surgery and becomes final at 6 months.

Meta-analyses have indicated that the expected improvement in sperm count from a varicocele repair is 9.71 to 12.32 million/mL, while motility improves by 10.86% and morphology by 9.69%.[6][15]

Infertile men with clinically significant varicoceles who have initial semen values of >8 million sperm/mL and >18% for progressive sperm motility have the best and most substantial improvement in their semen parameters after varicocelectomy surgery.[85] If the patient is a smoker or obese, outcomes from varicocele repair procedures will be negatively affected.[86] 

Surgery for infertility is not recommended for subclinical varicoceles by most experts or guidelines, as this will not typically affect fertility or improve semen parameters.[87][88]

Recently, the use of intraoperative indocyanine green angiography has been reported to help identify the testicular artery during microsurgical dissection for varicoceles.[89] The indocyanine green dye is given intravenously during the procedure. This causes arterial vessels to demonstrate an infrared fluorescence, facilitating their identification and preventing inadvertent arterial injuries.[89][90][91][92][93][94][95]

There is limited data on the treatment of recurrent or persistent varicoceles after a surgical procedure. A repeat procedure offers very good rates of varicocele resolution, improved semen parameters, and pain control.[96][97] A repeat surgery utilizing the same surgical approach is typically performed in most cases. It appears reasonable, although the quality of the published data and studies is low.[96] No comparison of the use of an alternate approach with a repeat procedure of the same modality has yet been performed.

Couples with infertility due to nonobstructive azoospermia and a varicocele may benefit from microsurgical testicular sperm extraction and intracytoplasmic sperm injection (ICSI).

A follow-up semen analysis is typically performed about 4 months after the varicocelectomy procedure. Spermatogenesis generally takes about 74 days, so any noticeable effect on sperm quality will take 3 to 4 months to become clinically apparent.[98]

A large global survey of urologists and male infertility specialists showed that many clinicians do not appear to follow established guidelines regarding surgical indications for varicocele repair and the management of subclinical varicoceles. The survey also indicated significant gaps in the published clinical practice guidelines, as many clinical situations were not included or addressed.[99]

Differential Diagnosis

A broad differential diagnosis for varicocele includes the following:

  • Epididymal tumors
  • Epididymitis
  • Hydrocele
  • Inguinal hernia
  • Paratesticular tumors
  • Scrotal lipomas and liposarcomas
  • Spermatocele
  • Testicular torsion
  • Testicular tumors
  • Trauma


The prognosis of a varicocele is quite good. If the varicocele is causing pain, this can be relieved with surgical repair. Improvement in semen parameters is generally noted in infertile men with abnormal semen parameters and clinically significant varicoceles. Varicocelectomy procedures for large varicoceles in adolescents with a small testis can allow testicular catch-up growth and help prevent future infertility.[4][21] Asymptomatic varicoceles in fertile men with normal testosterone levels do not need treatment and appear to cause no adverse effects.


Untreated clinically significant varicoceles may cause pain or discomfort and negatively affect fertility. In adolescents, they can affect the growth and size of the testes.[100]

Complications of surgery include scrotal hematomas, hydroceles, infection, scrotal tissue damage, wound infections, and arterial injury to the testis that may result in atrophy of the testis or even loss of the testicle.

Hydroceles may develop in up to 5% of varicocelectomy patients postoperatively. 

Scrotal wound infections will generally become apparent within 3 to 5 days after surgery. 

Testicular atrophy is rare even if the testicular artery is inadvertently ligated (5%), as there is adequate collateral arterial circulation from the cremasteric and vasal arteries. Inadvertent injuries to the testicular artery can be minimized by using optical magnification (loops) or performing microsurgery.

A recurrent varicocele may develop in up to 10% of treated patients.

Scrotal pain may develop after varicocele surgery. This is thought to be due to hydrocele formation, neuralgia, ureteral lesions, Nutcracker syndrome, varicocele recurrence, or referred pain from elsewhere.[101]

Deterrence and Patient Education

Patients diagnosed with clinically significant varicoceles should be informed of the possible harmful effects. If the varicocele is subclinical, there may not be an indication to repair it surgically. Surgery is not required if a varicocele is found incidentally in an otherwise asymptomatic, fertile male. A varicocelectomy procedure in an adolescent can help preserve future fertility and allow for increased growth of the testis.[4][21] All healthcare team members should reinforce the correct information about varicoceles to the patient and his family.

Pearls and Other Issues

Surgical repair is contradicted in asymptomatic patients with subclinical varicoceles, those with normal semen quality, and patients with isolated teratozoospermia.

If a varicocele is discovered during a vasectomy or vasectomy reversal, the varicocele repair should be delayed by 6 months to allow for the development of collateral vessels that will minimize the risk of delayed vascular compromise.

Varicocele repair is not of any benefit in patients who are pursuing intracytoplasmic sperm injection treatment.

Varicocelectomy surgery improves testosterone production and might be a viable option in selected hypogonadal men as an alternative to permanent or long-term testosterone supplementation.[86] 

Although rare, isolated significant right-sided varicoceles could be an indication of vena cava obstruction, such as from a right renal cancer venous tumor thrombus extending to the vena cava, especially if clinically large, unilateral, of sudden onset, or cannot be reduced.[58][59][60] In such cases, appropriate imaging is recommended, such as ultrasound. Most reported cases of such tumors will have other significant signs or symptoms of vena cava or retroperitoneal pathology.[61][62] 

In borderline cases, it may be possible in the future to perform sperm DNA fragmentation and oxidative stress testing to help identify which infertile patients would benefit from varicocele repair procedures.[102]

Enhancing Healthcare Team Outcomes

An interprofessional team approach to evaluating and treating varicoceles will result in the best outcomes.[103][104][105] Healthcare professionals involved in caring for patients with varicoceles should possess the clinical skills to accurately diagnose and manage the condition. This includes the ability to perform physical examinations, interpret imaging studies, and conduct minimally invasive surgical procedures.

Each healthcare team member has specific responsibilities in caring for patients with varicoceles. Physicians provide medical expertise and surgical interventions, while advanced care practitioners, nurses, and pharmacists contribute to patient education, medication management, and postoperative care.

A well-defined strategy involves developing clinical pathways and treatment guidelines for varicoceles, ensuring that evidence-based practices are followed. Health professionals should collaborate on treatment plans considering individual patient needs and preferences. 

Most varicoceles are discovered incidentally and do not require treatment unless symptomatic. In patients with infertility, varicoceles offer an opportunity to easily improve sperm count and function.[6][106] Primary care physicians, nurse practitioners, and physician assistants should be aware that the best available current evidence indicates that varicocele treatment should be offered to infertile males with a palpable or clinically significant varicocele and abnormal semen parameters. This also agrees with the current American Urological Association and European Association of Urology Guidelines regarding varicocele treatment.

Unfortunately, at this time, there are no available large randomized prospective trials of sufficient size, duration, and statistical validity to be considered absolutely definitive on the issue of varicocelectomy for male infertility. The best available evidence from large meta-analyses and other data supports the previously described conclusions, recommendations, and guidelines, which strongly support the value of corrective surgery for clinically significant varicoceles in male infertility patients with abnormal semen parameters.[6][7][8][9][12][13][14][15][16][106][107] However, multiple studies have shown no significant improvement in pregnancy rates nor sperm counts, morphology, or motility from repairs of subclinical varicoceles.[36][106]

Healthcare professionals must exchange information, share insights, and collaborate on patient care plans, treatment outcomes, and potential complications. Interprofessional communication and care coordination will enhance patient-centered care, improve outcomes, prioritize patient safety, and optimize team performance. This holistic approach ultimately leads to improved healthcare quality in patients affected with varicoceles.



Larry E. Siref


11/13/2023 12:13:28 AM



Yetkin E, Ozturk S. Dilating Vascular Diseases: Pathophysiology and Clinical Aspects. International journal of vascular medicine. 2018:2018():9024278. doi: 10.1155/2018/9024278. Epub 2018 Aug 26     [PubMed PMID: 30225143]


Paick S, Choi WS. Varicocele and Testicular Pain: A Review. The world journal of men's health. 2019 Jan:37(1):4-11. doi: 10.5534/wjmh.170010. Epub 2018 May 16     [PubMed PMID: 29774668]


Fallara G, Capogrosso P, Pozzi E, Belladelli F, Corsini C, Boeri L, Candela L, Schifano N, Dehò F, Castiglione F, Muneer A, Montorsi F, Salonia A. The Effect of Varicocele Treatment on Fertility in Adults: A Systematic Review and Meta-analysis of Published Prospective Trials. European urology focus. 2023 Jan:9(1):154-161. doi: 10.1016/j.euf.2022.08.014. Epub 2022 Sep 20     [PubMed PMID: 36151030]

Level 1 (high-level) evidence


Patil N, Javali T. Varicocelectomy in adolescents - Does it safeguard future fertility? A single centre experience. Journal of pediatric urology. 2022 Feb:18(1):5.e1-5.e10. doi: 10.1016/j.jpurol.2021.11.020. Epub 2021 Dec 5     [PubMed PMID: 34980555]


Lomboy JR, Coward RM. The Varicocele: Clinical Presentation, Evaluation, and Surgical Management. Seminars in interventional radiology. 2016 Sep:33(3):163-9. doi: 10.1055/s-0036-1586143. Epub     [PubMed PMID: 27582602]


Cannarella R, Shah R, Hamoda TAA, Boitrelle F, Saleh R, Gul M, Rambhatla A, Kavoussi P, Toprak T, Harraz AM, Ko E, Çeker G, Durairajanayagam D, Alkahidi N, Kuroda S, Crafa A, Henkel R, Salvio G, Hazir B, Darbandi M, Bendayan M, Darbandi S, Falcone M, Garrido N, Kosgi R, Sawaid Kaiyal R, Karna K, Phuoc NHV, Birowo P, Colpi GM, de la Rosette J, Pinggera GM, Nguyen Q, Zini A, Zohdy W, Singh R, Saini P, Glina S, Lin H, Mostafa T, Rojas-Cruz C, Arafa M, Calogero AE, Dimitriadis F, Kothari P, Karthikeyan VS, Okada K, Chiba K, Kadıoglu A, Altay B, Turunc T, Zilaitiene B, Gokalp F, Adamyan A, Katz D, Chung E, Mierzwa TC, Zylbersztejn DS, Paul GM, Sofikitis N, Sokolakis I, Malhotra V, Brodjonegoro SR, Adriansjah R, Tsujimura A, Amano T, Balercia G, Ziouziou I, Deswanto IA, Martinez M, Park HJ, Bakırcıoglu ME, Ceyhan E, Aydos K, Ramsay J, Minhas S, Al Hashimi M, Ghayda RA, Tadros N, Sindhwani P, Ho CCK, Rachman RI, Rodriguez Pena M, Motawi A, Ponnusamy AK, Dipankar S, Amir A, Binsaleh S, Serefoglu EC, Banthia R, Khalafalla K, Basukarno A, Bac NH, Singla K, Ambar RF, Makarounis K, Priyadarshi S, Duarsa GWK, Atmoko W, Jindal S, Arianto E, Akhavizadegan H, El Bardisi H, Shoshany O, Busetto GM, Moussa M, Jamali M, Al-Marhoon MS, Ruzaev M, Farsi HMA, Mutambirwa S, Lee DS, Kulaksiz D, Cheng YS, Bouzouita A, Sarikaya S, Kandil H, Tsampoukas G, Farkouh A, Bowa K, Savira M, Mogharabian N, Le TV, Harjanggi M, Anh DT, Long TQT, Soebadi MA, Hakim L, Tanic M, Ari UC, Parikh FR, Calik G, Kv V, Dorji G, Rezano A, Rajmil O, Tien DMB, Yuan Y, Lizarraga-Salas JF, Eze B, Ngoo KS, Lee J, Arslan U, Agarwal A, Global Andrology Forum. Does Varicocele Repair Improve Conventional Semen Parameters? A Meta-Analytic Study of Before-After Data. The world journal of men's health. 2023 Jun 22:():. doi: 10.5534/wjmh.230034. Epub 2023 Jun 22     [PubMed PMID: 37382284]


Franco A, Proietti F, Palombi V, Savarese G, Guidotti M, Leonardo C, Ferro F, Manna C, Franco G. Varicocele: To Treat or Not to Treat? Journal of clinical medicine. 2023 Jun 15:12(12):. doi: 10.3390/jcm12124062. Epub 2023 Jun 15     [PubMed PMID: 37373755]


Minhas S, Bettocchi C, Boeri L, Capogrosso P, Carvalho J, Cilesiz NC, Cocci A, Corona G, Dimitropoulos K, Gül M, Hatzichristodoulou G, Jones TH, Kadioglu A, Martínez Salamanca JI, Milenkovic U, Modgil V, Russo GI, Serefoglu EC, Tharakan T, Verze P, Salonia A, EAU Working Group on Male Sexual and Reproductive Health. European Association of Urology Guidelines on Male Sexual and Reproductive Health: 2021 Update on Male Infertility. European urology. 2021 Nov:80(5):603-620. doi: 10.1016/j.eururo.2021.08.014. Epub 2021 Sep 10     [PubMed PMID: 34511305]


Nakonechnyi Y, Nakonechnyi A, Fraczek M, Havrylyuk A, Kamieniczna M, Chopyak V, Kurpisz M. Varicocelectomy improves sperm parameters, sperm DNA integrity as well as the other critical semen features. Journal of physiology and pharmacology : an official journal of the Polish Physiological Society. 2022 Dec:73(6):. doi: 10.26402/jpp.2022.6.09. Epub 2023 Apr 17     [PubMed PMID: 37087568]


Ouanes Y, Rahoui M, Chaker K, Marrak M, Bibi M, Mrad Dali K, Sellami A, Ben Rhouma S, Nouira Y. Functional outcomes of surgical treatment of varicocele in infertile men: Comparison of three techniques. Annals of medicine and surgery (2012). 2022 Jun:78():103937. doi: 10.1016/j.amsu.2022.103937. Epub 2022 Jun 4     [PubMed PMID: 35734643]


Seiler F, Kneissl P, Hamann C, Jünemann KP, Osmonov D. Laparoscopic varicocelectomy in male infertility : Improvement of seminal parameters and effects on spermatogenesis. Wiener klinische Wochenschrift. 2022 Jan:134(1-2):51-55. doi: 10.1007/s00508-021-01897-w. Epub 2021 Jun 28     [PubMed PMID: 34181069]


Methorst C, Akakpo W, Graziana JP, Ferretti L, Yiou R, Morel-Journel N, Terrier JE, Beley S, Carnicelli D, Hupertan V, Madec FX, Faix A, Marcelli F, Huyghe E. [Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of Varicocele]. Progres en urologie : journal de l'Association francaise d'urologie et de la Societe francaise d'urologie. 2021 Mar:31(3):119-130. doi: 10.1016/j.purol.2020.11.006. Epub 2020 Dec 8     [PubMed PMID: 33308982]


Morini D, Spaggiari G, Daolio J, Melli B, Nicoli A, De Feo G, Valli B, Viola D, Garganigo S, Magnani E, Pilia A, Polese A, Colla R, Simoni M, Aguzzoli L, Villani MT, Santi D. Improvement of sperm morphology after surgical varicocele repair. Andrology. 2021 Jul:9(4):1176-1184. doi: 10.1111/andr.13012. Epub 2021 May 6     [PubMed PMID: 33825345]


Kalwaniya DS, Tolat A, Kumar D, Naga Rohith V. Modified Palomo Procedure Is an Effective Intervention for Improving Serum Testosterone Levels and Semen Parameters in Patients With Varicocele: A Prospective Study. Cureus. 2023 Feb:15(2):e35252. doi: 10.7759/cureus.35252. Epub 2023 Feb 21     [PubMed PMID: 36968902]


Baazeem A, Belzile E, Ciampi A, Dohle G, Jarvi K, Salonia A, Weidner W, Zini A. Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair. European urology. 2011 Oct:60(4):796-808. doi: 10.1016/j.eururo.2011.06.018. Epub 2011 Jul 5     [PubMed PMID: 21733620]

Level 1 (high-level) evidence


Agarwal A, Cannarella R, Saleh R, Boitrelle F, Gül M, Toprak T, Salvio G, Arafa M, Russo GI, Harraz AM, Singh R, Garrido N, Hamoda TAA, Rambhatla A, Kavoussi P, Kuroda S, Çalik G, Saini P, Ceyhan E, Dimitriadis F, Henkel R, Crafa A, Palani A, Duran MB, Maziotis E, Saïs É, Bendayan M, Darbandi M, Le TV, Gunes S, Tsioulou P, Sengupta P, Hazir B, Çeker G, Darbandi S, Durairajanayagam D, Aghamajidi A, Alkhalidi N, Sogutdelen E, Leisegang K, Alarbid A, Ho CCK, Malhotra V, Finocchi F, Crisóstomo L, Kosgi R, ElBardisi H, Zini A, Birowo P, Colpi G, Park HJ, Serefoglu EC, Nguyen Q, Ko E, de la Rosette J, Pinggera GM, Nguyen HVP, Kandil H, Shah R. Impact of Varicocele Repair on Semen Parameters in Infertile Men: A Systematic Review and Meta-Analysis. The world journal of men's health. 2023 Apr:41(2):289-310. doi: 10.5534/wjmh.220142. Epub 2022 Oct 28     [PubMed PMID: 36326166]

Level 1 (high-level) evidence


Lewis SEM. Revisiting the impact of varicocele and its treatments on male fertility. Reproductive biomedicine online. 2022 Dec:45(6):1061-1063. doi: 10.1016/j.rbmo.2022.07.004. Epub 2022 Jul 14     [PubMed PMID: 36207252]


Glick H, Claflin J, Heximer A, Fiestan GO, Varon D, Daignault-Newton S, Van Til M, Wan J, Kraft KH. Testicular catch-up growth in the non-operative management of the adolescent varicocele. Journal of pediatric urology. 2023 Oct:19(5):652.e1-652.e6. doi: 10.1016/j.jpurol.2023.06.003. Epub 2023 Jun 17     [PubMed PMID: 37394305]


Atassi O, Kass EJ, Steinert BW. Testicular growth after successful varicocele correction in adolescents: comparison of artery sparing techniques with the Palomo procedure. The Journal of urology. 1995 Feb:153(2):482-3     [PubMed PMID: 7815628]


Lemack GE, Uzzo RG, Schlegel PN, Goldstein M. Microsurgical repair of the adolescent varicocele. The Journal of urology. 1998 Jul:160(1):179-81     [PubMed PMID: 9628646]


Bedir F, Keskin E, Karabakan M, Karabulut İ, Yılmazel FK, Özbey EG, Aksoy Y, Özbey İ. Evaluation of testicular catch-up growth in adolescent microsurgical varicocelectomy. Turkish journal of urology. 2017 Jun:43(2):135-140. doi: 10.5152/tud.2017.51436. Epub 2017 May 3     [PubMed PMID: 28717535]


Shebl SE, Sabry K. Semen Parameters Changes in Adolescents With Clinical Varicocele after Magnified Subinguinal Varicocelectomy: A Prospective Controlled Study. American journal of men's health. 2022 Nov-Dec:16(6):15579883221141808. doi: 10.1177/15579883221141808. Epub     [PubMed PMID: 36536998]


Arafa M, Henkel R, Agarwal A, Majzoub A, Elbardisi H. Correlation of oxidation-reduction potential with hormones, semen parameters and testicular volume. Andrologia. 2019 Jun:51(5):e13258. doi: 10.1111/and.13258. Epub 2019 Feb 26     [PubMed PMID: 30809834]


Reesink DJ, Huisman PM, Wiltink J, Boeken Kruger AE, Lock TMTW. Sneeze and pop: a ruptured varicocele; analysis of literature, guided by a well-documented case-report. BMC urology. 2019 Jan 31:19(1):14. doi: 10.1186/s12894-019-0442-z. Epub 2019 Jan 31     [PubMed PMID: 30704438]

Level 3 (low-level) evidence


Gat Y, Bachar GN, Zukerman Z, Belenky A, Gornish M. Varicocele: a bilateral disease. Fertility and sterility. 2004 Feb:81(2):424-9     [PubMed PMID: 14967384]


AlQefari GB, Alduraibi KI, Almansour AA, Alghamdi A, Alsubhi MA. Nutcracker Phenomenon: A Rare Incidental Finding. Cureus. 2022 Dec:14(12):e32822. doi: 10.7759/cureus.32822. Epub 2022 Dec 22     [PubMed PMID: 36570111]


Penfold D, Lotfollahzadeh S. Nutcracker Syndrome. StatPearls. 2024 Jan:():     [PubMed PMID: 32644615]


Zhang H, Zhang N, Li M, Jin W, Pan S, Wang Z, Feng H. Treatment of six cases of left renal nutcracker phenomenon: surgery and endografting. Chinese medical journal. 2003 Nov:116(11):1782-4     [PubMed PMID: 14642161]

Level 3 (low-level) evidence


Wang NN, Dallas K, Li S, Baker L, Eisenberg ML. The association between varicocoeles and vascular disease: an analysis of U.S. claims data. Andrology. 2018 Jan:6(1):99-103. doi: 10.1111/andr.12437. Epub 2017 Dec 1     [PubMed PMID: 29195012]


Sigalos JT, Pastuszak AW. Chronic orchialgia: epidemiology, diagnosis and evaluation. Translational andrology and urology. 2017 May:6(Suppl 1):S37-S43. doi: 10.21037/tau.2017.05.23. Epub     [PubMed PMID: 28725616]


Jacobson DL, Johnson EK. Varicoceles in the pediatric and adolescent population: threat to future fertility? Fertility and sterility. 2017 Sep:108(3):370-377. doi: 10.1016/j.fertnstert.2017.07.014. Epub 2017 Aug 10     [PubMed PMID: 28803635]


Brannigan RE. Introduction: Varicoceles: a contemporary perspective. Fertility and sterility. 2017 Sep:108(3):361-363. doi: 10.1016/j.fertnstert.2017.07.1161. Epub     [PubMed PMID: 28865533]

Level 3 (low-level) evidence


Vaganée D, Daems F, Aerts W, Dewaide R, van den Keybus T, De Baets K, De Wachter S, De Win G. Testicular asymmetry in healthy adolescent boys. BJU international. 2018 Oct:122(4):654-666. doi: 10.1111/bju.14174. Epub 2018 Mar 23     [PubMed PMID: 29461677]


Peterson AC, Lance RS, Ruiz HE. Outcomes of varicocele ligation done for pain. The Journal of urology. 1998 May:159(5):1565-7     [PubMed PMID: 9554356]


Cho CL, Esteves SC, Agarwal A. Indications and outcomes of varicocele repair. Panminerva medica. 2019 Jun:61(2):152-163. doi: 10.23736/S0031-0808.18.03528-0. Epub     [PubMed PMID: 30990285]


Kohn TP, Ohlander SJ, Jacob JS, Griffin TM, Lipshultz LI, Pastuszak AW. The Effect of Subclinical Varicocele on Pregnancy Rates and Semen Parameters: a Systematic Review and Meta-Analysis. Current urology reports. 2018 May 17:19(7):53. doi: 10.1007/s11934-018-0798-8. Epub 2018 May 17     [PubMed PMID: 29774482]

Level 1 (high-level) evidence


Tanrikut C, Goldstein M. Varicocele repair for treatment of androgen deficiency. Current opinion in urology. 2010 Nov:20(6):500-2. doi: 10.1097/MOU.0b013e32833f1b5e. Epub     [PubMed PMID: 20852425]

Level 3 (low-level) evidence


Tanrikut C, McQuaid JW, Goldstein M. The impact of varicocele and varicocele repair on serum testosterone. Current opinion in obstetrics & gynecology. 2011 Aug:23(4):227-31. doi: 10.1097/GCO.0b013e328348a3e2. Epub     [PubMed PMID: 21681090]

Level 3 (low-level) evidence


Najari BB, Introna L, Paduch DA. Improvements in Patient-reported Sexual Function After Microsurgical Varicocelectomy. Urology. 2017 Dec:110():104-109. doi: 10.1016/j.urology.2016.04.044. Epub 2016 May 16     [PubMed PMID: 27196029]


Çayan S, Akbay E, Saylam B, Kadıoğlu A. Effect of Varicocele and Its Treatment on Testosterone in Hypogonadal Men with Varicocele: Review of the Literature. Balkan medical journal. 2020 Apr 10:37(3):121-124. doi: 10.4274/balkanmedj.galenos.2020.2020.1.85. Epub 2020 Feb 19     [PubMed PMID: 32070086]


Hayden RP, Tanrikut C. Testosterone and Varicocele. The Urologic clinics of North America. 2016 May:43(2):223-32. doi: 10.1016/j.ucl.2016.01.009. Epub 2016 Mar 21     [PubMed PMID: 27132580]


Bernie HL, Goldstein M. Varicocele Repair Versus Testosterone Therapy for Older Hypogonadal Men with Clinical Varicocele and Low Testosterone. European urology focus. 2018 Apr:4(3):314-316. doi: 10.1016/j.euf.2018.09.017. Epub 2018 Oct 11     [PubMed PMID: 30316825]


Lehner K, Ingram C, Bansal U, Baca C, Balasubramanian A, Thirumavalavan N, Scovell JM, Rajanahally S, Pollard M, Lipshultz LI. Color Doppler ultrasound imaging in varicoceles: Is the difference in venous diameter encountered during Valsalva predictive of palpable varicocele grade? Asian journal of urology. 2023 Jan:10(1):27-32. doi: 10.1016/j.ajur.2021.12.006. Epub 2022 Jan 4     [PubMed PMID: 36721684]


Karami M, Mazdak H, Khanbabapour S, Adibi A, Nasr N. Determination of the best position and site for color Doppler ultrasonographic evaluation of the testicular vein to define the clinical grades of varicocele ultrasonographically. Advanced biomedical research. 2014:3():17. doi: 10.4103/2277-9175.124647. Epub 2014 Jan 9     [PubMed PMID: 24592367]


Pilatz A, Altinkilic B, Köhler E, Marconi M, Weidner W. Color Doppler ultrasound imaging in varicoceles: is the venous diameter sufficient for predicting clinical and subclinical varicocele? World journal of urology. 2011 Oct:29(5):645-50. doi: 10.1007/s00345-011-0701-4. Epub 2011 May 24     [PubMed PMID: 21607575]


Nagappan P, Keene D, Ferrara F, Shabani A, Cervellione RM. Antegrade venography identifies parallel venous duplications in the majority of adolescents with varicocele. The Journal of urology. 2015 Jan:193(1):286-90. doi: 10.1016/j.juro.2014.07.081. Epub 2014 Jul 21     [PubMed PMID: 25058868]


Keene DJ, Cervellione RM. Intravenous methylene blue venography during laparoscopic paediatric varicocelectomy. Journal of pediatric surgery. 2014 Feb:49(2):308-11; discussion 311. doi: 10.1016/j.jpedsurg.2013.11.045. Epub 2013 Nov 15     [PubMed PMID: 24528974]


Sze DY, Kao JS, Frisoli JK, McCallum SW, Kennedy WA 2nd, Razavi MK. Persistent and recurrent postsurgical varicoceles: venographic anatomy and treatment with N-butyl cyanoacrylate embolization. Journal of vascular and interventional radiology : JVIR. 2008 Apr:19(4):539-45. doi: 10.1016/j.jvir.2007.11.009. Epub     [PubMed PMID: 18375298]


Hannick JH, Blais AS, Kim JK, Traubici J, Shiff M, Book R, Lorenzo AJ. Prevalence, Doppler Ultrasound Findings, and Clinical Implications of the Nutcracker Phenomenon in Pediatric Varicoceles. Urology. 2019 Jun:128():78-83. doi: 10.1016/j.urology.2019.03.001. Epub 2019 Mar 16     [PubMed PMID: 30885542]


Shakeri S, Malekmakan L, Manaheji F, Tadayon T. Inter-observer agreement on varicoceles diagnosis among patients referred to Shiraz Namazi Hospital. International journal of reproductive biomedicine. 2018 Oct:16(10):649-652     [PubMed PMID: 30643858]


Rocher L, Gennisson JL, Baranger J, Rachas A, Criton A, Izard V, Bertolloto M, Bellin MF, Correas JM. Ultrasensitive Doppler as a tool for the diagnosis of testicular ischemia during the Valsalva maneuver: a new way to explore varicoceles? Acta radiologica (Stockholm, Sweden : 1987). 2019 Aug:60(8):1048-1056. doi: 10.1177/0284185118810981. Epub 2018 Nov 5     [PubMed PMID: 30396287]


Karlović K, Kuliš T, Lukić I, Kolarić D, Milas I, Miškić B, Antonini S, Kaštelan Ž. SCROTAL THERMOGRAPHY IN THE EVALUATION OF SURGICAL OUTCOME AFTER VARICOCELE REPAIR: A CASE REPORT. Acta clinica Croatica. 2022 Aug:61(2):359-363. doi: 10.20471/acc.2022.61.02.24. Epub     [PubMed PMID: 36818916]

Level 3 (low-level) evidence


Yüzkan S, Çilengir AH. Shear Wave Elastography for Assessment of Testicular Stiffness in Patients with Varicocele: A Prospective Comparative Study. Journal of medical ultrasound. 2022 Oct-Dec:30(4):277-281. doi: 10.4103/jmu.jmu_218_21. Epub 2022 May 3     [PubMed PMID: 36844770]

Level 2 (mid-level) evidence


Cao W, Han H, Guan X, Lyu C, Zhou Q, Tian L, Guo R. Elastography and contrast-enhanced ultrasound to assess the effect of varicocelectomy: A case-controlled study. Andrologia. 2022 Dec:54(11):e14586. doi: 10.1111/and.14586. Epub 2022 Oct 10     [PubMed PMID: 36217608]

Level 2 (mid-level) evidence


Alperen K, Ayca S, Unal T, Han GK, Sadik G. Testes Parenchymal Shear Wave Elastography Findings in Varicocele. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP. 2022 Jul:32(7):855-859. doi: 10.29271/jcpsp.2022.07.855. Epub     [PubMed PMID: 35795931]


Mulati Y, Li X, Maimaitiming A, Apizi A, Wang Y. Is there any predictive value of testicular shear wave elastic modulus in testicular functions for varicocele patients? Andrologia. 2022 Jun:54(5):e14393. doi: 10.1111/and.14393. Epub 2022 Mar 11     [PubMed PMID: 35277869]


Hadad Z, Norup K, Petersen C. [Right-sided varicocele testis as the only sign of right-sided renal tumour]. Ugeskrift for laeger. 2016 Feb 1:178(5):V05140307     [PubMed PMID: 26857303]


Bonfitto M, Kimura LSM, Godoy JMP, Zeratti Filho M, Spessoto LCF, Facio FN Jr. Does right-sided varicocele indicate a right-sided kidney tumor? Archivio italiano di urologia, andrologia : organo ufficiale [di] Societa italiana di ecografia urologica e nefrologica. 2019 Mar 29:91(1):53-54. doi: 10.4081/aiua.2019.1.53. Epub 2019 Mar 29     [PubMed PMID: 30932432]


Itani M, Kipper B, Corwin MT, Burgan CM, Fetzer DT, Shenoy-Bhangle AS, Althubaity A, Loehfelm TW, Middleton WD, Fananapazir G. Right-sided scrotal varicocele and its association with malignancy: a multi-institutional study. Abdominal radiology (New York). 2021 May:46(5):2140-2145. doi: 10.1007/s00261-020-02840-9. Epub 2020 Nov 5     [PubMed PMID: 33151361]


El-Saeity NS, Sidhu PS. "Scrotal varicocele, exclude a renal tumour". Is this evidence based? Clinical radiology. 2006 Jul:61(7):593-9     [PubMed PMID: 16784945]


Horrow MM. Further Workup for Isolated Right-Sided Varicocele. AJR. American journal of roentgenology. 2019 Aug:213(2):W95. doi: 10.2214/AJR.19.21339. Epub     [PubMed PMID: 31328994]


Gleason A, Bishop K, Xi Y, Fetzer DT. Isolated Right-Sided Varicocele: Is Further Workup Necessary? AJR. American journal of roentgenology. 2019 Apr:212(4):802-807. doi: 10.2214/AJR.18.20077. Epub 2019 Feb 19     [PubMed PMID: 30779666]


Hanna GB, Byrne D, Townell N. Right-sided varicocele as a presentation of right renal tumours. British journal of urology. 1995 Jun:75(6):798-9     [PubMed PMID: 7613843]


Neves da Silva HV, Meller RL, Ogundipe EA, Rochon PJ. Varicoceles: Overview of Treatment from a Radiologic and Surgical Perspective. Seminars in interventional radiology. 2022 Oct:39(5):490-497. doi: 10.1055/s-0042-1757939. Epub 2022 Dec 20     [PubMed PMID: 36561940]

Level 3 (low-level) evidence


Crestani A, Giannarini G, Calandriello M, Rossanese M, Mancini M, Novara G, Ficarra V. Antegrade scrotal sclerotherapy of internal spermatic veins for varicocele treatment: technique, complications, and results. Asian journal of andrology. 2016 Mar-Apr:18(2):292-5. doi: 10.4103/1008-682X.171658. Epub     [PubMed PMID: 26763550]


Keene DJB, Cervellione RM. Antegrade sclerotherapy in adolescent varicocele patients. Journal of pediatric urology. 2017 Jun:13(3):305.e1-305.e6. doi: 10.1016/j.jpurol.2016.12.018. Epub 2017 Jan 29     [PubMed PMID: 28215837]


Yan S, Shabbir M, Yap T, Homa S, Ramsay J, McEleny K, Minhas S. Should the current guidelines for the treatment of varicoceles in infertile men be re-evaluated? Human fertility (Cambridge, England). 2021 Apr:24(2):78-92. doi: 10.1080/14647273.2019.1582807. Epub 2019 Mar 23     [PubMed PMID: 30905210]


Jensen CFS, Khan O, Nagras ZG, Sønksen J, Fode M, Østergren PB, Shah T, Ohl DA, CopMich Collaborative. Male infertility problems of patients with strict sperm morphology between 5-14% may be missed with the current WHO guidelines. Scandinavian journal of urology. 2018 Oct-Dec:52(5-6):427-431. doi: 10.1080/21681805.2018.1548503. Epub 2019 Jan 3     [PubMed PMID: 30602328]


Silay MS, Hoen L, Quadackaers J, Undre S, Bogaert G, Dogan HS, Kocvara R, Nijman RJM, Radmayr C, Tekgul S, Stein R. Treatment of Varicocele in Children and Adolescents: A Systematic Review and Meta-analysis from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel. European urology. 2019 Mar:75(3):448-461. doi: 10.1016/j.eururo.2018.09.042. Epub 2018 Oct 10     [PubMed PMID: 30316583]

Level 1 (high-level) evidence


Colpi GM, Francavilla S, Haidl G, Link K, Behre HM, Goulis DG, Krausz C, Giwercman A. European Academy of Andrology guideline Management of oligo-astheno-teratozoospermia. Andrology. 2018 Jul:6(4):513-524. doi: 10.1111/andr.12502. Epub     [PubMed PMID: 30134082]


Broe MP, Ryan JPC, Ryan EJ, Murphy DJ, Mulvin DW, Cantwell C, Brophy DP. Spermatic vein embolization as a treatment for symptomatic varicocele. Canadian Urological Association journal = Journal de l'Association des urologues du Canada. 2021 Nov:15(11):E569-E573. doi: 10.5489/cuaj.7077. Epub     [PubMed PMID: 33999803]


Halpern J, Mittal S, Pereira K, Bhatia S, Ramasamy R. Percutaneous embolization of varicocele: technique, indications, relative contraindications, and complications. Asian journal of andrology. 2016 Mar-Apr:18(2):234-8. doi: 10.4103/1008-682X.169985. Epub     [PubMed PMID: 26658060]


Liu Q, Zhang X, Zhou F, Xi X, Lian S, Lian Q. Comparing Endovascular and Surgical Treatments for Varicocele: A Systematic Review and Meta-Analysis. Journal of vascular and interventional radiology : JVIR. 2022 Jul:33(7):834-840.e2. doi: 10.1016/j.jvir.2022.03.013. Epub 2022 Mar 18     [PubMed PMID: 35314371]

Level 1 (high-level) evidence


Chung KLY, Hung JWS, Yam FSD, Chao NSY, Li DCY, Leung MWY. Prospective Randomized Controlled Trial Comparing Laparoscopic Palomo Surgery vs Scrotal Antegrade Sclerotherapy in Adolescent Varicocele. The Journal of urology. 2023 Mar:209(3):600-610. doi: 10.1097/JU.0000000000003087. Epub 2022 Dec 8     [PubMed PMID: 36475807]

Level 1 (high-level) evidence


Fabiani A, Pavia MP, Stramucci S, Antezza A, De Stefano V, Castellani D. Do sclero-embolization procedures have advantages over surgical ligature in treating varicocele in children, adolescents and adults? Results from a systematic review and meta-analysis. Andrologia. 2022 Sep:54(8):e14510. doi: 10.1111/and.14510. Epub 2022 Jun 24     [PubMed PMID: 35750057]

Level 1 (high-level) evidence


Soetandar A, Noegroho BS, Siregar S, Adriansjah R, Mustafa A. Microsurgical varicocelectomy effects on sperm DNA fragmentation and sperm parameters in infertile male patients: A systematic review and meta-analysis of more recent evidence. Archivio italiano di urologia, andrologia : organo ufficiale [di] Societa italiana di ecografia urologica e nefrologica. 2022 Sep 27:94(3):360-365. doi: 10.4081/aiua.2022.3.360. Epub 2022 Sep 27     [PubMed PMID: 36165486]

Level 1 (high-level) evidence


Majzoub A, ElBardisi H, Covarrubias S, Mak N, Agarwal A, Henkel R, ElSaid S, Al-Malki AH, Arafa M. Effect of microsurgical varicocelectomy on fertility outcome and treatment plans of patients with severe oligozoospermia: An original report and meta-analysis. Andrologia. 2021 Jul:53(6):e14059. doi: 10.1111/and.14059. Epub 2021 Mar 24     [PubMed PMID: 33763931]

Level 1 (high-level) evidence


Li Z, Hu S, Zhou R, Wang J. Comparison of the efficacy and safety of microscopic and laparoscopic surgery for varicocele. World journal of urology. 2022 Jan:40(1):299-300. doi: 10.1007/s00345-020-03516-1. Epub 2020 Nov 10     [PubMed PMID: 33169185]


Abdel-Meguid TA, Al-Sayyad A, Tayib A, Farsi HM. Does varicocele repair improve male infertility? An evidence-based perspective from a randomized, controlled trial. European urology. 2011 Mar:59(3):455-61. doi: 10.1016/j.eururo.2010.12.008. Epub 2010 Dec 21     [PubMed PMID: 21196073]

Level 1 (high-level) evidence


Owen RC, McCormick BJ, Figler BD, Coward RM. A review of varicocele repair for pain. Translational andrology and urology. 2017 May:6(Suppl 1):S20-S29. doi: 10.21037/tau.2017.03.36. Epub     [PubMed PMID: 28725614]


Yuan R, Zhuo H, Cao D, Wei Q. Efficacy and safety of varicocelectomies: A meta-analysis. Systems biology in reproductive medicine. 2017 Apr:63(2):120-129. doi: 10.1080/19396368.2016.1265161. Epub 2017 Feb 14     [PubMed PMID: 28301253]

Level 1 (high-level) evidence


Niu Y, Wang D, Chen Y, Pokhrel G, Xu H, Wang T, Wang S, Liu J. Comparison of clinical outcome of bilateral and unilateral varicocelectomy in infertile males with left clinical and right subclinical varicocele: A meta-analysis of randomised controlled trials. Andrologia. 2018 Nov:50(9):e13078. doi: 10.1111/and.13078. Epub 2018 Jul 19     [PubMed PMID: 30024042]

Level 1 (high-level) evidence


Ou N, Zhu J, Zhang W, Liang Z, Hu R, Song Y, Yang Y, Liu X. Bilateral is superior to unilateral varicocelectomy in infertile men with bilateral varicocele: Systematic review and meta-analysis. Andrologia. 2019 Dec:51(11):e13462. doi: 10.1111/and.13462. Epub 2019 Oct 23     [PubMed PMID: 31646672]

Level 1 (high-level) evidence


Sun XL, Wang JL, Peng YP, Gao QQ, Song T, Yu W, Xu ZP, Chen Y, Dai YT. Bilateral is superior to unilateral varicocelectomy in infertile males with left clinical and right subclinical varicocele: a prospective randomized controlled study. International urology and nephrology. 2018 Feb:50(2):205-210. doi: 10.1007/s11255-017-1749-x. Epub 2017 Dec 5     [PubMed PMID: 29210007]

Level 1 (high-level) evidence


Shabana W, Teleb M, Dawod T, Elsayed E, Desoky E, Shahin A, Eladl M, Sorour W. Predictors of improvement in semen parameters after varicocelectomy for male subfertility: A prospective study. Canadian Urological Association journal = Journal de l'Association des urologues du Canada. 2015 Sep-Oct:9(9-10):E579-82. doi: 10.5489/cuaj.2808. Epub 2015 Sep 9     [PubMed PMID: 26425217]


El-Dighidy MA, Sherief MH, Shamaa MA, El-Sakka AI. Smoking and obesity negatively affect the favourable outcome of varicocelectomy in sub-fertile men. Andrologia. 2021 Sep:53(8):e14131. doi: 10.1111/and.14131. Epub 2021 Jun 12     [PubMed PMID: 34117798]


Rodriguez Peña M, Alescio L, Russell A, Lourenco da Cunha J, Alzu G, Bardoneschi E. Predictors of improved seminal parameters and fertility after varicocele repair in young adults. Andrologia. 2009 Oct:41(5):277-81. doi: 10.1111/j.1439-0272.2009.00919.x. Epub     [PubMed PMID: 19737275]


Cho PS, Yu RN, Paltiel HJ, Migliozzi MA, Li X, Venna A, Diamond DA. Clinical outcome of pediatric and young adult subclinical varicoceles: a single-institution experience. Asian journal of andrology. 2021 Nov-Dec:23(6):611-615. doi: 10.4103/aja.aja_22_21. Epub     [PubMed PMID: 33885004]

Level 2 (mid-level) evidence


Cho CL, Ho KL, Chan WK, Chu RW, Law IC. Use of indocyanine green angiography in microsurgical subinguinal varicocelectomy - lessons learned from our initial experience. International braz j urol : official journal of the Brazilian Society of Urology. 2017 Sep-Oct:43(5):974-979. doi: 10.1590/S1677-5538.IBJU.2017.0107. Epub     [PubMed PMID: 28727390]


Esposito C, Borgogni R, Autorino G, Cerulo M, Carulli R, Esposito G, Del Conte F, Escolino M. Applications of Indocyanine Green-Guided Near-Infrared Fluorescence Imaging in Pediatric Minimally Invasive Surgery Urology: A Narrative Review. Journal of laparoendoscopic & advanced surgical techniques. Part A. 2022 Dec:32(12):1280-1287. doi: 10.1089/lap.2022.0231. Epub 2022 Nov 25     [PubMed PMID: 36450121]

Level 3 (low-level) evidence


Cho CL, Chu RWH. Indocyanine green angiography and lymphography in microsurgical subinguinal varicocelectomy with evolving video microsurgery and fluorescence imaging platforms. Hong Kong medical journal = Xianggang yi xue za zhi. 2022 Apr:28(2):181.e1-181.e2. doi: 10.12809/hkmj219470. Epub     [PubMed PMID: 35470806]


Cho CL. Improved Arterial Preservation achieved by Combined Use of Indocyanine Green Angiography and Doppler Detector during Microsurgical Subinguinal Varicocelectomy. Journal of investigative surgery : the official journal of the Academy of Surgical Research. 2020 Dec:33(10):948-949. doi: 10.1080/08941939.2019.1580324. Epub 2019 Mar 19     [PubMed PMID: 33222577]


Teng J, Jia Z, Ai X, Luo X, Guan Y, Hao X, Fei W. Robotic-assisted laparoscopic artery-sparing varicocelectomy using indocyanine green fluorescence angiography: Initial experience. Andrologia. 2020 Dec:52(11):e13774. doi: 10.1111/and.13774. Epub 2020 Aug 12     [PubMed PMID: 32786090]


Kurihara S, Shibata Y, Arai S, Sekine Y, Miyazawa Y, Koike H, Matsui H, Ito K, Suzuki K, Nakamura T. Improved Arterial Preservation Achieved by Combined Use of Indocyanine Green Angiography and Doppler Detector During Microsurgical Subinguinal Varicocelectomy. Journal of investigative surgery : the official journal of the Academy of Surgical Research. 2020 Dec:33(10):941-947. doi: 10.1080/08941939.2019.1577516. Epub 2019 May 9     [PubMed PMID: 31070068]


Shibata Y, Kurihara S, Arai S, Kato H, Suzuki T, Miyazawa Y, Koike H, Ito K, Nakamura T, Suzuki K. Efficacy of Indocyanine Green Angiography on Microsurgical Subinguinal Varicocelectomy. Journal of investigative surgery : the official journal of the Academy of Surgical Research. 2017 Aug:30(4):247-251. doi: 10.1080/08941939.2016.1236855. Epub 2016 Oct 13     [PubMed PMID: 27736254]


Fallara G, Tang S, Pang KH, Pozzi E, Belladelli F, Schifano N, Capogrosso P, Alnajjar HM, Montorsi F, Salonia A, Castiglione F, Muneer A, ESSM Scientific Collaboration and Partnership (ESCAP). Treatment of Persistent or Recurrent Varicoceles: A Systematic Review. European urology focus. 2023 May:9(3):531-540. doi: 10.1016/j.euf.2022.11.008. Epub 2022 Nov 25     [PubMed PMID: 36443199]

Level 1 (high-level) evidence


Mahdi M, Majzoub A, Khalafalla K, To J, Aviles-Sandoval M, Elbardisi H, AlSaid S, Agarwal A, Henkel R, Arafa M. Effect of redo varicocelectomy on semen parameters and pregnancy outcome: An original report and meta-analysis. Andrologia. 2022 Nov:54(10):e14525. doi: 10.1111/and.14525. Epub 2022 Jul 17     [PubMed PMID: 35842930]

Level 1 (high-level) evidence


Griswold MD. Spermatogenesis: The Commitment to Meiosis. Physiological reviews. 2016 Jan:96(1):1-17. doi: 10.1152/physrev.00013.2015. Epub     [PubMed PMID: 26537427]


Shah R, Agarwal A, Kavoussi P, Rambhatla A, Saleh R, Cannarella R, Harraz AM, Boitrelle F, Kuroda S, Hamoda TAA, Zini A, Ko E, Calik G, Toprak T, Kandil H, Gül M, Bakırcıoğlu ME, Parekh N, Russo GI, Tadros N, Kadioglu A, Arafa M, Chung E, Rajmil O, Dimitriadis F, Malhotra V, Salvio G, Henkel R, Le TV, Sogutdelen E, Vij S, Alarbid A, Gudeloglu A, Tsujimura A, Calogero AE, El Meliegy A, Crafa A, Kalkanli A, Baser A, Hazir B, Giulioni C, Cho CL, Ho CCK, Salzano C, Zylbersztejn DS, Tien DMB, Pescatori E, Borges E, Serefoglu EC, Saïs-Hamza E, Huyghe E, Ceyhan E, Caroppo E, Castiglioni F, Bahar F, Gokalp F, Lombardo F, Gadda F, Duarsa GWK, Pinggera GM, Busetto GM, Balercia G, Cito G, Blecher G, Franco G, Liguori G, Elbardisi H, Keskin H, Lin H, Taniguchi H, Park HJ, Ziouziou I, de la Rosette J, Hotaling J, Ramsay J, Molina JMC, Lo KL, Bocu K, Khalafalla K, Bowa K, Okada K, Nagao K, Chiba K, Hakim L, Makarounis K, Hehemann M, Rodriguez Peña M, Falcone M, Bendayan M, Martinez M, Timpano M, Altan M, Fode M, Al-Marhoon MS, Sadighi Gilani MA, Soebadi MA, Gherabi N, Sofikitis N, Kahraman O, Birowo P, Kothari P, Sindhwani P, Javed Q, Ambar RF, Kosgi R, Ghayda RA, Adriansjah R, Condorelli RA, La Vignera S, Micic S, Kim SHK, Fukuhara S, Ahn ST, Mostafa T, Ong TA, Takeshima T, Amano T, Barrett T, Arslan U, Karthikeyan VS, Atmoko W, Yumura Y, Yuan Y, Kato Y, Jezek D, Cheng BK, Hatzichristodoulou G, Dy J, Castañé ER, El-Sakka AI, Nguyen Q, Sarikaya S, Boeri L, Tan R, Moussa MA, El-Assmy A, Alali H, Alhathal N, Osman Y, Perovic D, Sajadi H, Akhavizadegan H, Vučinić M, Kattan S, Kattan MS, Mogharabian N, Phuoc NHV, Ngoo KS, Alkandari MH, Alsuhaibani S, Sokolakis I, Babaei M, King MS, Diemer T, Gava MM, Henrique R, Silva RSE, Paul GM, Mierzwa TC, Glina S, Siddiqi K, Wu H, Wurzacher J, Farkouh A, Son H, Minhas S, Lee J, Magsanoc N, Capogrosso P, Albano GJ, Lewis SEM, Jayasena CN, Alvarez JG, Teo C, Smith RP, Chua JBM, Jensen CFS, Parekattil S, Finelli R, Durairajanayagam D, Karna KK, Ahmed A, Evenson D, Umemoto Y, Puigvert A, Çeker G, Colpi GM, Global Andrology Forum. Consensus and Diversity in the Management of Varicocele for Male Infertility: Results of a Global Practice Survey and Comparison with Guidelines and Recommendations. The world journal of men's health. 2023 Jan:41(1):164-197. doi: 10.5534/wjmh.220048. Epub 2022 Jun 13     [PubMed PMID: 35791302]

Level 2 (mid-level) evidence


Kass EJ, Stork BR, Steinert BW. Varicocele in adolescence induces left and right testicular volume loss. BJU international. 2001 Apr:87(6):499-501     [PubMed PMID: 11298042]


Lai CZ, Chen SJ, Huang CP, Chen HY, Tsai MY, Liu PL, Chen YH, Chen WC. Scrotal Pain after Varicocelectomy: A Narrative Review. Biomedicines. 2023 Apr 1:11(4):. doi: 10.3390/biomedicines11041070. Epub 2023 Apr 1     [PubMed PMID: 37189688]

Level 3 (low-level) evidence


Arya D, Balasinor N, Singh D. Varicocoele-associated male infertility: Cellular and molecular perspectives of pathophysiology. Andrology. 2022 Nov:10(8):1463-1483. doi: 10.1111/andr.13278. Epub 2022 Sep 12     [PubMed PMID: 36040837]

Level 3 (low-level) evidence


Pagani RL, Ohlander SJ, Niederberger CS. Microsurgical varicocele ligation: surgical methodology and associated outcomes. Fertility and sterility. 2019 Mar:111(3):415-419. doi: 10.1016/j.fertnstert.2019.01.002. Epub     [PubMed PMID: 30827515]


Wang H, Ji ZG. Microsurgery Versus Laparoscopic Surgery for Varicocele: A Meta-Analysis and Systematic Review of Randomized Controlled Trials. Journal of investigative surgery : the official journal of the Academy of Surgical Research. 2020 Jan:33(1):40-48. doi: 10.1080/08941939.2018.1474979. Epub 2018 Oct 19     [PubMed PMID: 30339469]

Level 1 (high-level) evidence


Zavattaro M, Ceruti C, Motta G, Allasia S, Marinelli L, Di Bisceglie C, Tagliabue MP, Sibona M, Rolle L, Lanfranco F. Treating varicocele in 2018: current knowledge and treatment options. Journal of endocrinological investigation. 2018 Dec:41(12):1365-1375. doi: 10.1007/s40618-018-0952-7. Epub 2018 Oct 3     [PubMed PMID: 30284221]


Schlegel PN, Sigman M, Collura B, De Jonge CJ, Eisenberg ML, Lamb DJ, Mulhall JP, Niederberger C, Sandlow JI, Sokol RZ, Spandorfer SD, Tanrikut C, Treadwell JR, Oristaglio JT, Zini A. Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline PART II. The Journal of urology. 2021 Jan:205(1):44-51. doi: 10.1097/JU.0000000000001520. Epub 2020 Dec 9     [PubMed PMID: 33295258]


Shridharani A, Owen RC, Elkelany OO, Kim ED. The significance of clinical practice guidelines on adult varicocele detection and management. Asian journal of andrology. 2016 Mar-Apr:18(2):269-75. doi: 10.4103/1008-682X.172641. Epub     [PubMed PMID: 26806081]

Level 1 (high-level) evidence