The presence of a varicocele is determined by physical examination, Doppler sonography confirms the persistence of a retrograde flow during the Valsalva maneuver. A painful varicocele is generally large in size and easily diagnosed. The skin is horizontally incised medial to the anterior superior iliac spine, the external oblique muscle is incised, the internal oblique is retracted and the peritoneum is teased away. At this level the vein is generally unique and easy to ligate. The surgical approach on the right side may also be more difficult because the right gonadal vein drains into the inferior vena cava.
Inguinal ligation is performed through a low inguinal incision.
The aponeurosis of the external oblique is incised and the spermatic cord isolated. The spermatic fascia is incised and the dilated veins are dissected, ligated and excised. This allows a complete arrest of internal drainage. Then, during a new maneuver he injects a sclerosing solution, a wire coil or a detachable balloon. There is, however, a small risk of migration of the sclerosing agent or coil and it also exposes the patient to rather unnecessary irradiation.