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OUTCOMES OF VARICOCELE LIGATION DONE FOR PAIN
0022-5347/98/1595-1565$03.00/0 THE JOURNAL OF UROLOGY Copyright 0 1998 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 159,1565-1567. May 1998 Printed in USA.
OUTCOMES OF VARICOCELE LIGATION DONE FOR PAIN ANDREW C. PETERSON, RAYMOND S . LANCE
AND
HENRY E. RUIZ
From the Urology Service, Madigan Army Medical Center, Tacoma, Washington
ABSTRACT
Purpose: Surgical ligation is an option in the management of patients with painful varicocele. Little objective data exist addressing the effectiveness of this treatment. We reviewed records from 58 patients who underwent varicocele ligation a t our institution from January 1985 to May 1996 to establish success of surgical ligation of the painful varicocele. Materials and Methods: ICD-9 billing codes were used to identify all patients who had undergone varicocele ligation for pain since 1985.We documented patient age, grade and location of varicocele, duration and quality of pain, response to conservative therapy and surgical approach to ligation. Telephone interviews and chart reviews were conducted to determine resolution of pain, complications of the procedure and if the patient would choose surgery again. Results: We obtained followup on 35 of the 58 painful varicocele patients (60%).Average patient age was 25.7 years (range 15 to 65). The varicocele was on the leR side in 30 men and bilateral in 5. Of the patients 31 described the pain as a dull throbbing ache, 2 as sharp and 2 as a pulling sensation. Initial conservative therapy failed in all 35 men. Varicocele was grade I11 in 18 cases, grade I1 in 16 and grade I in 1. The inguinal or subinguinal approach was used in 24 patients, high ligation in 10 and laparoscopic repair in 1. In 30 patients there was (86%) complete resolution of pain postoperatively and 1 had partial resolution. Only 4 patients (11%) had persistent or worse symptoms. Conclusions: This retrospective review supports the conclusion that varicocele ligation is an effective treatment for painful varicocele in properly selected patients. KEYWORDS: varicocele, ligation, pain
Surgical therapy for varicocele has been advocated primarily for patients with male factor infertility. After many studies most authors agree that surgery is an accepted form of management. Varicocele ligation for the treatment of pain is controversial with a paucity of literature supporting its use. Based on data from studies comparing different ligation techniques in patients with pain and infertility, we can estimate that the incidence of pain in individuals with varicoceles is 2 to l O % . 1 - 4 The most common complaint of these patients is a dull throbbing pain that worsens with straining and exer~ i s e We . ~ performed a retrospective chart review with followup interviews on all varicocele ligations performed for pain at our institution to determine the effectiveness of this modality of treatment. MATERIALS AND METHODS
ICD-9 billing codes were used to identify all patients who had undergone varicocele ligation from January 1985 to May 1996 at Madigan Army Medical Center. Only those patients who had undergone ligation for pain were included in the study. Charts were reviewed to document patient age and race, varicocele grade and location, duration and quality of pain, response to conservative therapy and surgical approach to ligation. Varicocele grade was obtained from preoperative notes, and history and physical examination reports. Varicocele grades were defined as grade I-palpable only with Valsalva, grade 11-palpable without Valsalva, and grade 111-visible from a distance. Comprehensive outpatient chart reviews and telephone contact were used to determine resolution of pain, complications of the procedure and if the Patient would choose surgery again for the same problem. RESULTS
Since January 1985 to May 1996,95 patients have undergone varicocele ligation at Madigan Army Medical Center. Of Accepted for publication November 14, 1997.
those men 37 (39%)were operated on for infertility and 58 (61%)for pain. Of the 58 men operated on for pain 35 (60%) were available for followup, including 19 by outpatient chart review and 16 by telephone interview. Average patient age at varicocele ligation for pain was 25.7 years (range 15 to 65). Race was white in 31 cases, African-American in 2 and Hispanic in 2. Average duration of pain before presentation to a health care provider was 17.8 months (range 3 months to 8 years). Average followup after surgery was 10.9 months (range 1 month to 7 years). All patients previously underwent a trial of conservative management, consisting of scrotal support, nonsteroid anti-inflammatory medication and physical activity limitations, such as no lifting greater than 10 pounds and no strenuous activity before surgery. "he varicocele was on the left side in 30 patients and bilateral in 5. Varicocele was grade I11 in 18 cases, grade I1 in 16 and grade I in 1. Concurrent scrota1 or testicular pathology was uncommon with 1 chord lipoma reported at the time of surgery. No patients reported a history of epididymitis, sexually transmitted diseases, urinary tract infections or prostatitis. Of the 35 patients followed after surgery 22 (63%) described the preoperative pain as dull and throbbing, 9 (26%)as a throbbing ache, 2 (6%)as a pulling sensation and 2 (6%)as sharp. None of the subjects described parasthesias or radiation of pain outside the groin area at the preoperative screening. A subinguinal approach was used in 24 patients (69%),high ligation in 10 (29%)and laparoscopic repair in 1 (3%). "here were no intraoperative complications. Postoperative complications consisted of 2 wound infections treated with oral antibiotics, 3 hydroceles, 1 hematoma and 1 loss of testicle with nonresolution of pain. One patient with a wound infection had undergone high ligation and the other inguinal ligation. All patients with postoperative hydroceles had undergone inguinal ligation. "he patient with the hematoma as well as with the loss of testicle had undergone inguinal liga-
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OUTCOMES OF VARICOCELE LIGATION DONE FOR PAIN
The major differences between the study of Biggers and tion. There were no deaths reported as a complication in any Soderdahl and ours are based on the patient population and of the procedures. Of the 35 patients contacted after surgery 30 (86%)re- surgical technique used. Strict patient selection based on ported complete resolution of pain, 1 (3%)had partial reso- duration, type and description of pain as well as prior conlution of pain and complained of occasional dull ache in the servative management may account for our success. Most groin similar to the pain before surgery and 4 had atypical men in our study described the pain as dull, aching and pain, including sharp pain (2) and a pulling sensation (2). In throbbing with only 1 patient complaining of sharp, radiating the latter 2 men pain resolved. In 4 cases (11%)symptoms pain. Conversely, many of the patients of Biggers and persisted or worsened postoperatively. All 4 varicoceles in Soderdahl complained of a n aching pain that radiated to the the failure group were on the left side, 2 were grade I11 and medial thigh and groin, which suggests that quality of pain 2 were grade 11. Of these 4 men 2 had undergone high and 2 may be an important indicator of success with surgical ligainguinal ligations. One patient also underwent a n attempt at tion. Biggers and Soderdahl also used the high ligation techradiographic embolization after inguinal ligation failed. De- nique, while we used mainly the transinguinal approach. The spite the complications 3 of the 4 men in the failure group high recurrence rate reported with high ligation may also stated that they would try the same surgical procedure again have contributed to the 26 failures reported by Biggers and Soderdahl. if offered. The large numbers of patients lost to followup may contribute to a significant source of error and possibly represent DISCUSSION a selection bias towards successful cases. Followup loss is an The incidence of varicocele is 10 to 20%of the male popu- inherent problem in the transient military population t h a t is lation in the United States, making this a common anatom- the subject of our study. We also based our assignment of ical abnormality.5.6 Treatment for painful varicocele tradi- varicocele grade on the subjective evaluation by many differtionally consists of conservative measures followed by ent physicians who examined these patients for preoperative surgery. Conservative efforts consist of scrotal support, anti- evaluation. Since we have no way to verify these assessinflammatory medications and limitations in activity often ments, we must accept them as accurate. Postoperative teleleading to unacceptable lifestyle limitations. Surgical tech- phone followup without reexamination is less than ideal niques include high, inguinal, subinguinal, scrotal and lapa- when trying to establish reasons for failed surgical manageroscopic ligation. Scrota1 ligation is rarely used today and the ment. It is necessary to know the percentage of those in the high ligation and retroperitoneal approaches are subject followup group with residual or recurrent varicocele. Without to high recurrence rates ranging h m 1 to 8%because of ingui- these data it is impossible to establish whether surgical mannal and retroperitoneal collateral veins. Conventional inguinal agement failed in those patients because of residual or recurligation is used most often today and is associated with the rent varicocele or from other causes. However, we know from least amount of complications and the lowest recurrence prior studies that the recurrence rate after inguinal varicorate.7-9 cele ligation is 0 to 2 % , ' ~ ~which .7 is much lower than the We have performed 95 varicocele ligations since January failure rate reported in our series. Therefore, varicocele re1985, including 58 (61%)for pain. This high proportion of currence and persistence alone cannot account for those with patients presenting to surgery for pain is unusual and much residual pain after surgical management. It is also impossihigher than that reported in the literature, which we believe ble to address the long-term postoperative complications, is due to the highly select patient population consisting of such as testicular atrophy, hydrocele and epidydimitis, of the young, physically active soldiers we care for at our institu- 16 telephone followup cases. However, there were no recurtion. In this population lifestyle and activity limitation are rences or long-term complications documented on the outpaoften unacceptable, therefore causing more patients to seek tient charts of the remaining 19 patients. surgical intervention. It is encouraging to note that of the 35 CONCLUSIONS patients available for followup 30 (86%)had complete resolution of the preoperative pain syndrome with few complicaOur data suggest that varicocele ligation for pain is suctions. Duration of preoperative pain, age, race, varicocele cessful when performed in a highly select population of men grade and response to conservative preoperative manage- who have specific pain complaints and in whom conservative ment did not accurately predict outcomes of varicocele liga- management has failed. A prospective, randomized study tion performed for pain. It is possible that our success with that compares conservative management to surgical correcsurgical treatment depends on the highly select patient pop- tion for painful varicocele is required to answer definitively ulation and our use of conservative therapy as an initial trial. the question of the benefits of surgical ligation. While we cannot definitively state that surgery is responsible REFERENCES for the resolution of the pain in our study, we note that resolution of the pain is temporally related to surgery within 1. GSS, E. J. and Bogdan, M.: Results of varicocele surgery in adolescents: a comparison of techniques. J. Urol., 148: 694, the first few weeks. Also, the vast majority of patients stated 1992. that they would attempt surgery again for the same problem. 2. Steckel, J., Dicker, A. P. and Goldstein, M.: Relationship beA literature search of MEDLINE dating back to 1969 shows tween varicocele size and response to varicocelectomy. J.Urol., only 1 other study addressing outcomes in patients treated 149 769, 1993. with varicocele ligation for pain. 3. Ito, H., Kotake, T., Hamano, M. and Yanagi, S.:Results obtained Biggers and Soderdahl performed a retrospective chart from microsurgical therapy of varicocele. Urol. Int., 51: 225, review of 50 patients undergoing ligation of the left internal 1993. spermatic vein for painful varicocele.10 Average patient age 4. Marmar, J. L. and Kim, Y.: Sublingual microsurgical varicocewas 20.7 years (range 18 to 51) and average pain duration lectomy: a technical critique and statistical analysis of semen and pregnancy data. J. Urol., 1 5 2 1127, 1994. was 13.8 months (range 10 to 12 years). Most patients com5. Saypol, D. C.: The varicocele. J. Androl., 2 61, 1981. plained of left intrascrotal pain with radiation to the groin 6. Meacham, R. B., Townsend, R. R., Rademacher, D. and Drose, and medial thigh. Only 19 of these patients (38%)had unJ. A.: The incidence of varicoceles in the general population dergone a trial of conservative therapy, consisting of scrotal when evaluated by physical examination, gray scale sonosupport and life-style limitation before surgery. Only 24 pagraphic and color doppler sonography. J. Urol., 151: 1535, tients (48%) operated on for painful varicocele in their study 1994. reported pain resolution. These results differ drastically from 7. Sayfan, J.,Soffer, Y. and Orda, R.: Varicocele treatment: prospecours. tive randomized trial of 3 methods. J. Urol., 148: 1447,1992.
OUTCOMES OF VARICOCELE LIGATION DONE FOR PAIN
8. Lissos, I. and Spiro, F. I.: Non-operative treatment of varicocele. S. Afr. Med. J., 7 0 805,1986. 9. Cvitanic, 0.A.: Varicocele: postoperative prevalence-a prospective study with color doppler ultrasound. Radiology, lE?: 711, 1993. 10. Biggers, R.D.and Soderdahl, D. W.: The painful varicocele. Mil. Med., 146: 440, 1981.
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form an objective opinion based on their own experience. This study does provide data that varimele ligation is a reasonable treatment option for many patients with a painful varicocele. However, the authors are correct in stating that a prospective randomized study comparing conservative management with surgical correction is required to answer the question definitively. It would appear as if the military would be the ideal environment to recruit a large number of individuals with a painful varicocele for such an effort.
EDITORIAL COMMENT Although there is a great deal of subjectivity in the data presented, this study does address a problem that many practitioners face. Unfortunately most urologists see only an occasional varicocele patient who presents primarily with scrotal pain and, therefore, cannot
Evan J. Kass Pediatric Urology William Beaumont Hospital Royal Oak, Michigan
Vol. 159,1565-1567. May 1998 Printed in USA.
OUTCOMES OF VARICOCELE LIGATION DONE FOR PAIN ANDREW C. PETERSON, RAYMOND S . LANCE
AND
HENRY E. RUIZ
From the Urology Service, Madigan Army Medical Center, Tacoma, Washington
ABSTRACT
Purpose: Surgical ligation is an option in the management of patients with painful varicocele. Little objective data exist addressing the effectiveness of this treatment. We reviewed records from 58 patients who underwent varicocele ligation a t our institution from January 1985 to May 1996 to establish success of surgical ligation of the painful varicocele. Materials and Methods: ICD-9 billing codes were used to identify all patients who had undergone varicocele ligation for pain since 1985.We documented patient age, grade and location of varicocele, duration and quality of pain, response to conservative therapy and surgical approach to ligation. Telephone interviews and chart reviews were conducted to determine resolution of pain, complications of the procedure and if the patient would choose surgery again. Results: We obtained followup on 35 of the 58 painful varicocele patients (60%).Average patient age was 25.7 years (range 15 to 65). The varicocele was on the leR side in 30 men and bilateral in 5. Of the patients 31 described the pain as a dull throbbing ache, 2 as sharp and 2 as a pulling sensation. Initial conservative therapy failed in all 35 men. Varicocele was grade I11 in 18 cases, grade I1 in 16 and grade I in 1. The inguinal or subinguinal approach was used in 24 patients, high ligation in 10 and laparoscopic repair in 1. In 30 patients there was (86%) complete resolution of pain postoperatively and 1 had partial resolution. Only 4 patients (11%) had persistent or worse symptoms. Conclusions: This retrospective review supports the conclusion that varicocele ligation is an effective treatment for painful varicocele in properly selected patients. KEYWORDS: varicocele, ligation, pain
Surgical therapy for varicocele has been advocated primarily for patients with male factor infertility. After many studies most authors agree that surgery is an accepted form of management. Varicocele ligation for the treatment of pain is controversial with a paucity of literature supporting its use. Based on data from studies comparing different ligation techniques in patients with pain and infertility, we can estimate that the incidence of pain in individuals with varicoceles is 2 to l O % . 1 - 4 The most common complaint of these patients is a dull throbbing pain that worsens with straining and exer~ i s e We . ~ performed a retrospective chart review with followup interviews on all varicocele ligations performed for pain at our institution to determine the effectiveness of this modality of treatment. MATERIALS AND METHODS
ICD-9 billing codes were used to identify all patients who had undergone varicocele ligation from January 1985 to May 1996 at Madigan Army Medical Center. Only those patients who had undergone ligation for pain were included in the study. Charts were reviewed to document patient age and race, varicocele grade and location, duration and quality of pain, response to conservative therapy and surgical approach to ligation. Varicocele grade was obtained from preoperative notes, and history and physical examination reports. Varicocele grades were defined as grade I-palpable only with Valsalva, grade 11-palpable without Valsalva, and grade 111-visible from a distance. Comprehensive outpatient chart reviews and telephone contact were used to determine resolution of pain, complications of the procedure and if the Patient would choose surgery again for the same problem. RESULTS
Since January 1985 to May 1996,95 patients have undergone varicocele ligation at Madigan Army Medical Center. Of Accepted for publication November 14, 1997.
those men 37 (39%)were operated on for infertility and 58 (61%)for pain. Of the 58 men operated on for pain 35 (60%) were available for followup, including 19 by outpatient chart review and 16 by telephone interview. Average patient age at varicocele ligation for pain was 25.7 years (range 15 to 65). Race was white in 31 cases, African-American in 2 and Hispanic in 2. Average duration of pain before presentation to a health care provider was 17.8 months (range 3 months to 8 years). Average followup after surgery was 10.9 months (range 1 month to 7 years). All patients previously underwent a trial of conservative management, consisting of scrotal support, nonsteroid anti-inflammatory medication and physical activity limitations, such as no lifting greater than 10 pounds and no strenuous activity before surgery. "he varicocele was on the left side in 30 patients and bilateral in 5. Varicocele was grade I11 in 18 cases, grade I1 in 16 and grade I in 1. Concurrent scrota1 or testicular pathology was uncommon with 1 chord lipoma reported at the time of surgery. No patients reported a history of epididymitis, sexually transmitted diseases, urinary tract infections or prostatitis. Of the 35 patients followed after surgery 22 (63%) described the preoperative pain as dull and throbbing, 9 (26%)as a throbbing ache, 2 (6%)as a pulling sensation and 2 (6%)as sharp. None of the subjects described parasthesias or radiation of pain outside the groin area at the preoperative screening. A subinguinal approach was used in 24 patients (69%),high ligation in 10 (29%)and laparoscopic repair in 1 (3%). "here were no intraoperative complications. Postoperative complications consisted of 2 wound infections treated with oral antibiotics, 3 hydroceles, 1 hematoma and 1 loss of testicle with nonresolution of pain. One patient with a wound infection had undergone high ligation and the other inguinal ligation. All patients with postoperative hydroceles had undergone inguinal ligation. "he patient with the hematoma as well as with the loss of testicle had undergone inguinal liga-
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OUTCOMES OF VARICOCELE LIGATION DONE FOR PAIN
The major differences between the study of Biggers and tion. There were no deaths reported as a complication in any Soderdahl and ours are based on the patient population and of the procedures. Of the 35 patients contacted after surgery 30 (86%)re- surgical technique used. Strict patient selection based on ported complete resolution of pain, 1 (3%)had partial reso- duration, type and description of pain as well as prior conlution of pain and complained of occasional dull ache in the servative management may account for our success. Most groin similar to the pain before surgery and 4 had atypical men in our study described the pain as dull, aching and pain, including sharp pain (2) and a pulling sensation (2). In throbbing with only 1 patient complaining of sharp, radiating the latter 2 men pain resolved. In 4 cases (11%)symptoms pain. Conversely, many of the patients of Biggers and persisted or worsened postoperatively. All 4 varicoceles in Soderdahl complained of a n aching pain that radiated to the the failure group were on the left side, 2 were grade I11 and medial thigh and groin, which suggests that quality of pain 2 were grade 11. Of these 4 men 2 had undergone high and 2 may be an important indicator of success with surgical ligainguinal ligations. One patient also underwent a n attempt at tion. Biggers and Soderdahl also used the high ligation techradiographic embolization after inguinal ligation failed. De- nique, while we used mainly the transinguinal approach. The spite the complications 3 of the 4 men in the failure group high recurrence rate reported with high ligation may also stated that they would try the same surgical procedure again have contributed to the 26 failures reported by Biggers and Soderdahl. if offered. The large numbers of patients lost to followup may contribute to a significant source of error and possibly represent DISCUSSION a selection bias towards successful cases. Followup loss is an The incidence of varicocele is 10 to 20%of the male popu- inherent problem in the transient military population t h a t is lation in the United States, making this a common anatom- the subject of our study. We also based our assignment of ical abnormality.5.6 Treatment for painful varicocele tradi- varicocele grade on the subjective evaluation by many differtionally consists of conservative measures followed by ent physicians who examined these patients for preoperative surgery. Conservative efforts consist of scrotal support, anti- evaluation. Since we have no way to verify these assessinflammatory medications and limitations in activity often ments, we must accept them as accurate. Postoperative teleleading to unacceptable lifestyle limitations. Surgical tech- phone followup without reexamination is less than ideal niques include high, inguinal, subinguinal, scrotal and lapa- when trying to establish reasons for failed surgical manageroscopic ligation. Scrota1 ligation is rarely used today and the ment. It is necessary to know the percentage of those in the high ligation and retroperitoneal approaches are subject followup group with residual or recurrent varicocele. Without to high recurrence rates ranging h m 1 to 8%because of ingui- these data it is impossible to establish whether surgical mannal and retroperitoneal collateral veins. Conventional inguinal agement failed in those patients because of residual or recurligation is used most often today and is associated with the rent varicocele or from other causes. However, we know from least amount of complications and the lowest recurrence prior studies that the recurrence rate after inguinal varicorate.7-9 cele ligation is 0 to 2 % , ' ~ ~which .7 is much lower than the We have performed 95 varicocele ligations since January failure rate reported in our series. Therefore, varicocele re1985, including 58 (61%)for pain. This high proportion of currence and persistence alone cannot account for those with patients presenting to surgery for pain is unusual and much residual pain after surgical management. It is also impossihigher than that reported in the literature, which we believe ble to address the long-term postoperative complications, is due to the highly select patient population consisting of such as testicular atrophy, hydrocele and epidydimitis, of the young, physically active soldiers we care for at our institu- 16 telephone followup cases. However, there were no recurtion. In this population lifestyle and activity limitation are rences or long-term complications documented on the outpaoften unacceptable, therefore causing more patients to seek tient charts of the remaining 19 patients. surgical intervention. It is encouraging to note that of the 35 CONCLUSIONS patients available for followup 30 (86%)had complete resolution of the preoperative pain syndrome with few complicaOur data suggest that varicocele ligation for pain is suctions. Duration of preoperative pain, age, race, varicocele cessful when performed in a highly select population of men grade and response to conservative preoperative manage- who have specific pain complaints and in whom conservative ment did not accurately predict outcomes of varicocele liga- management has failed. A prospective, randomized study tion performed for pain. It is possible that our success with that compares conservative management to surgical correcsurgical treatment depends on the highly select patient pop- tion for painful varicocele is required to answer definitively ulation and our use of conservative therapy as an initial trial. the question of the benefits of surgical ligation. While we cannot definitively state that surgery is responsible REFERENCES for the resolution of the pain in our study, we note that resolution of the pain is temporally related to surgery within 1. GSS, E. J. and Bogdan, M.: Results of varicocele surgery in adolescents: a comparison of techniques. J. Urol., 148: 694, the first few weeks. Also, the vast majority of patients stated 1992. that they would attempt surgery again for the same problem. 2. Steckel, J., Dicker, A. P. and Goldstein, M.: Relationship beA literature search of MEDLINE dating back to 1969 shows tween varicocele size and response to varicocelectomy. J.Urol., only 1 other study addressing outcomes in patients treated 149 769, 1993. with varicocele ligation for pain. 3. Ito, H., Kotake, T., Hamano, M. and Yanagi, S.:Results obtained Biggers and Soderdahl performed a retrospective chart from microsurgical therapy of varicocele. Urol. Int., 51: 225, review of 50 patients undergoing ligation of the left internal 1993. spermatic vein for painful varicocele.10 Average patient age 4. Marmar, J. L. and Kim, Y.: Sublingual microsurgical varicocewas 20.7 years (range 18 to 51) and average pain duration lectomy: a technical critique and statistical analysis of semen and pregnancy data. J. Urol., 1 5 2 1127, 1994. was 13.8 months (range 10 to 12 years). Most patients com5. Saypol, D. C.: The varicocele. J. Androl., 2 61, 1981. plained of left intrascrotal pain with radiation to the groin 6. Meacham, R. B., Townsend, R. R., Rademacher, D. and Drose, and medial thigh. Only 19 of these patients (38%)had unJ. A.: The incidence of varicoceles in the general population dergone a trial of conservative therapy, consisting of scrotal when evaluated by physical examination, gray scale sonosupport and life-style limitation before surgery. Only 24 pagraphic and color doppler sonography. J. Urol., 151: 1535, tients (48%) operated on for painful varicocele in their study 1994. reported pain resolution. These results differ drastically from 7. Sayfan, J.,Soffer, Y. and Orda, R.: Varicocele treatment: prospecours. tive randomized trial of 3 methods. J. Urol., 148: 1447,1992.
OUTCOMES OF VARICOCELE LIGATION DONE FOR PAIN
8. Lissos, I. and Spiro, F. I.: Non-operative treatment of varicocele. S. Afr. Med. J., 7 0 805,1986. 9. Cvitanic, 0.A.: Varicocele: postoperative prevalence-a prospective study with color doppler ultrasound. Radiology, lE?: 711, 1993. 10. Biggers, R.D.and Soderdahl, D. W.: The painful varicocele. Mil. Med., 146: 440, 1981.
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form an objective opinion based on their own experience. This study does provide data that varimele ligation is a reasonable treatment option for many patients with a painful varicocele. However, the authors are correct in stating that a prospective randomized study comparing conservative management with surgical correction is required to answer the question definitively. It would appear as if the military would be the ideal environment to recruit a large number of individuals with a painful varicocele for such an effort.
EDITORIAL COMMENT Although there is a great deal of subjectivity in the data presented, this study does address a problem that many practitioners face. Unfortunately most urologists see only an occasional varicocele patient who presents primarily with scrotal pain and, therefore, cannot
Evan J. Kass Pediatric Urology William Beaumont Hospital Royal Oak, Michigan