Observation or treatment of paediatric varicoceles: revisiting the evidence

Paediatric varicocele is a common condition affecting ~15% of male adolescents. There is no consensus on an optimal management strategy given that robust data identifying adolescents at risk of long-term testicular dysfunction remain limited. Clinical decision-making is further complicated by heterogeneity in grade, laterality, age at diagnosis and testicular volume disparity. Features favouring observation include low grade, <10% volume asymmetry, hormonal and semen parameters within reference ranges, and low peak retrograde flow on Doppler ultrasonography. Conversely, findings associated with increased risk of future gonadal impairment include high-grade or bilateral varicocele, testicular asymmetry >20%, elevated retrograde flow velocities, and hormonal and semen abnormalities. By synthesizing the available evidence, we propose a risk-stratified model to aid clinicians in selecting appropriate candidates for observation versus early intervention and to guide surveillance through adolescence.