Varicocele: Current controversies in pathophysiology and treatment

Although varicocele is generally regarded as the most common and easily correctable cause of male factor infertility, controversy continues to surround its pathophysiology and treatment. Most likely, a varicocele is the result of a multifactorial process including a longer left internal spermatic vein with its right‐angle insertion into the left renal vein and the absence of valves, which causes a higher hydrostatic pressure resulting in dilatation. Much of the pathophysiology is still unknown, increased blood flow causing an elevated intratesticular temperature may be important. The best method for diagnosis remains a good clinical examination. A key to patient counselling regarding varicocele treatment is an understanding of outcomes data and various predictive factors for response. Positive gonadotrophin‐releasing hormone stimulation test, normal serum follicle‐stimulating hormone level, grade III varicocele, normal testicular size, total motile sperm count more than 5 million per ejaculate and absence of genetic defect are associated with improved outcomes following varicocelectomy. Surgical ligation is still the preferred method of treatment. Percutaneous treatment is reserved for recurrent varicoceles after failure of surgical ligation.