presentation of varicocele

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What is a varicocele?

Varicocele is a term used to describe abnormally dilated veins (called the “pampiniform plexus” of veins) in the scrotum.

How does a varicocele form?

Veins throughout the body carry blood from various organs back to the heart. Normally, they have valves that ensure the blood moves in the proper direction. However, when valves in the testicular vein don’t work properly, gravity can make blood collect in the scrotum, causing a varicocele. They usually occur on the left side, likely related to the course of the testicular vein in the abdomen.

How common are varicoceles?

Varicocele’s are very common, and they are not dangerous. In fact, 15% of all adult men have a varicocele. For many men, their varicocele will go unnoticed throughout their life, or it will not cause any problems at all. About 20% of adolescents have varicoceles, so a fraction of them likely resolve spontaneously.

What problems are associated with varicoceles?

Varicoceles can cause three main problems: Impaired fertility, decreased testosterone production by the testis, or scrotal discomfort. For this reason, they are not usually treated unless there is reason for concern about one of these problems. In some cases, varicocele can cause azoospermia , or the complete lack of sperm in the ejaculate. Since varicoceles are so common and since they usually go undetected throughout life, likely around 80% of men with varicoceles are able to conceive with their partners without any medical intervention. Also, as mentioned above, most men with varicoceles do not experience hormonal issues or discomfort. One important consideration is that larger varicoceles seem to have greater adverse effects. See below for the size classification of varicoceles.

How does a varicocele affect the testis?

There are numerous theories, but most agree that one way is by carrying warm blood from the abdomen down towards the testis in the scrotum. The testis functions optimally at around 3 degrees below body temperature, thus this warmer blood can affect its ability to make sperm and testosterone. Other theories include mass effect on the testis as well as exposing the testis to various chemicals from the adrenal gland, which sits near the top of the testicular vein.

Are varicoceles dangerous?

Varicoceles are not life threatening, but rarely they can be associated with dangerous conditions. For example, if a varicocele forms on the right side and not the left, it is important to make sure there is no mass or other abnormality in the abdomen that might be causing it. Also, varicoceles should “reduce” or decrease in fullness when a patient is lying down since the gravity no longer fills the pampiniform plexus of veins. When a varicocele doesn’t reduce, it also raises concern that there is an abdominal blockage such as a mass or tumor that could be causing the mass. Finally, it seems varicoceles almost always have effects on testosterone production. However, many men with varicoceles will maintain satisfactory levels of testosterone throughout their lives without treatment. In rare cases, however, varicocele could lead to severely low testosterone, with its associated complications including metabolic syndrome, diabetes, and osteoporosis.

What is the “Grading” system for varicocele size?

Varicocele grading systems help characterize the size of varicocele, which then helps to guide treatment. Various systems have been created, but below is the most commonly used scale today:

Even within Grades II and III, there can be varying sizes appreciated by experienced physicians, and the findings can help decide whether or not to treat the varicocele.

Can varicoceles cause problems later in life?

Data from Johns Hopkins and other institutions suggests that both fertility parameters and testosterone levels can both be progressively affected over time. For example, varicoceles are more common in men who have previously fathered children, but are currently having difficulty conceiving. Also, almost all men who undergo varicocele repair see increased testosterone levels after repair. (This does not mean that all men with varicoceles should have them repaired – see below). Importantly, this does not mean that all men with varicoceles should be treated. As mentioned above, many men do just fine throughout their lives without ever knowing they had a varicocele.

How is a varicocele detected?

“Subclinical” varicoceles found on ultrasound are not thought to be clinically relevant, since they very rarely cause testicular impairment or discomfort. In few cases, ultrasound may detect varicoceles when physical exam is difficult due to the patient’s anatomy, or when other findings lead a physician to order a scrotal ultrasound. Large varicoceles can often be seen with the naked eye, or a patient can feel something resembling a “bag of worms” in their scrotum. More commonly, however, a varicocele is only detected upon examination by a physician. Thus, the best way to detect a varicocele is by careful physical examination by a urologist. Even seasoned general urologists often are not confident about the diagnosis, so if there is any doubt, one should obtain an ultrasound and/or see a physician specializing in varicoceles and other scrotal pathology.

When are varicoceles usually found?

Varicoceles are usually found due to one of the following scenarios:

Most commonly, its found in a completely asymptomatic man being evaluated for infertility.

A mass in the scrotum may be detected by the patient or by a physician during routine exam.

A man may present to a physician with pain in the scrotum.

What kind of pain does a varicocele can a varicocele cause?

For most patients, varicocele does not cause any noticeable discomfort. However, mild or severe scrotal pain can result from varicocele. Patients typically report an “aching” sensation in the scrotum, usually associated with prolonged standing or activity. The discomfort is commonly relieved by lying supine (on one’s back) and raising one’s feet. Varicoceles may cause more severe pain if the veins develop thrombophlebitis (blood clotting and inflammation). The evaluation of patients with scrotal pain should include scrotal ultrasonography to rule out other pathology and urine tests to rule out infection. Repair of a varicocele may be considered when there is no other identifiable cause of the pain and the pain qualities are consistent with a varicocele, however there can be no guarantee that varicocele repair will eradicate the pain. In the modern era, microsurgical denervation of the spermatic cord should also be considered at the time of varicocele ligation in patients with scrotal pain.

Varicocele and Fertility

Varicoceles are found on physical examination of roughly one-third of men being evaluated for failure to conceive. They are categorized by size (see the grading system, above) and by their presence on one or both sides of the scrotum. It is important to know that varicoceles of all sizes may affect fertility. In addition, new evidence shows that sperm function may be affected by varicoceles in ways that are not detected by semen analysis. A varicocele on one side of the scrotum has an effect on both testes in regards to function and temperature. As mentioned before, varicoceles that cannot be felt by the physician but are diagnosed by ultrasound or other imaging studies are not considered clinically significant.

When Should a Varicocele Be Repaired?

It’s important to have an individualized approach to varicocele management. The decision to treat a varicocele is made based on the size of the varicocele, the patient’s fertility goals, symptoms of low testosterone levels or scrotal discomfort, blood tests such as testosterone levels, and/or semen analysis findings. Also, the age and fertility of the patient’s female partner are very important factors to consider when deciding whether or not to treat a varicocele. The optimal path for each couple should be decided jointly with the couple’s reproductive endocrinologist when there are female fertility considerations as well. If the female partner has not yet been evaluated, she should undergo basic testing to ensure there are no findings that would change the management of a varicocele. There is strong evidence to suggest that repairing a varicocele improves testicular function and may prevent any further testicular damage over time, but this correlates closely with the size of the varicocele. Thus, testicular function should be assessed directly by semen analysis, measurement of testis volume, and/or blood tests. If there is evidence of damage to the testicle, varicocele repair might be important to improve testicular function and/or prevent further decline. When the testis appears to be unaffected by the varicocele, there are varying opinions on whether to treat a varicocele. If you desire varicocele ligation to protect future testicular function, it is important to have a thorough discussion with your surgeon, and to have realistic expectations about the chances of any measurable benefit, and the risks of side effects from the procedure. We only favor treating a patient for any condition when this “risk to benefit ratio” is favorable. An alternative to treatment is to observe patients with varicoceles over time by checking serial semen analyses and / or blood tests, and only treating if there is evidence that the varicocele is impairing testicular function. Repair of a varicocele in the male partner of an infertile couple is indicated when:

There is objective evidence of a male factor (e.g. abnormal semen analysis),

The wife’s fertility status is intact or treatable, AND

There are no other obvious causes for male infertility (i.e. obstruction, malignancy, or genetic abnormality).

How is a Varicocele Repaired?

There are three categories of approaches: With varicocele embolization, small coils are introduced through a vein in the groin area and are used to block the veins in the abdomen feeding the varicocele. The long-term success rates seem to be slightly lower compared to an open surgical approach, and treatment can take more than one procedure. However, there is no incision, so we often strongly consider this approach for children. In addition, it is sometimes used in patients with a previously failed surgical repair, pain as the main indication for surgery, and body features that increase the risk of surgery such as morbid obesity. In laparoscopic varicocele ligation, a camera and small instruments are introduced to the abdomen, where the veins feeding the varicocele are clipped. This procedure also has lower long-term success rates. In addition, although complications are rare, when they do occur they can be far more serious than other approaches. Finally, the rate of hydrocele (collection of fluid around the testis) after surgery is higher with this approach. Finally, there are multiple open surgical approaches. For most patients, we perform a microsurgical subinguinal varicocele ligation. This approach yields the highest success rates and lowest complication rates, has the lowest cost, and essentially eliminates the risk of dangerous intra-abdominal injuries.

How is microsurgical subinguinal varicocele ligation performed?

For this procedure, the patient is asleep under general anesthesia. An incision is made in the lower groin area, and the spermatic cord is isolated. All of the veins feeding the varicocele are identified and divided, while important structures for testicular function are preserved. The image below shows the key structures at >20X magnification. Veins have been divided between black silk suture, while all important structures have been protected.

Why perform a subinguinal microsurgical operation?

The subinguinal approach allows us to avoid cutting muscle fibers, leading to less pain and decreased risk of hernia after surgery.

The use of our state-of-the-art surgical microscope to carefully preserve important structures helps prevent complications (such as hydrocele) while dividing the veins contributing to the varicocele.

How many days are spent in the hospital?

Microsurgical varicocelectomy is an outpatient procedure, so patients typically go home the same day.

What are the complications of varicocele repaired?

Potential complications from varicocele repair include persistent/recurrent varicocele, bruising, infection and testicular tenderness. A hydrocele, collection of water around the testis, occurs in an extremely small number of men. For those patients undergoing the non-surgical repair, there is the added risk of reaction to the contrast agent used in the procedure. Finally, there is an extremely low risk of loss of the testicle. Insurance typically covers microsurgical varicocelectomy.

How Does Repairing a Varicocele Positively Affect Fertility?

In 540 infertile men with a clinical palpable varicocele who underwent microsurgical varicocelectomy and were followed more than 1 and 2 years postoperatively for alterations in semen quality and conception, respectively:

A greater than 50% increase in total motile sperm count, was observed in 271 patients (50%).

An overall spontaneous pregnancy rate of 36.6% was achieved after varicocelectomy with a mean time to conception of 7 months (range 1 to 19).

Of preoperative In-Vitro Fertilization/Intra Cytoplasmic Sperm Injection (IVF and ICSI) candidates, 31% became Intrauterine Insemination (IUI) candidates.

Of all IUI candidates 42% gained the potential for spontaneous pregnancy.

Microsurgical Varicocelectomy has significant potential not only to obviate the need for assisted reproductive technology, but also to down stage or shift the level of assisted reproductive technology needed to bypass male factor infertility.

Cayan S, Turek PJ. J Urol. 2002 Apr;167(4):1749-52 This means that repairing a clinically significant varicocele can significantly improve semen parameters and allow for natural conception or lessen the need of reproductive assistance.

Does varicocele ligation affect testosterone production?

For most patients, testosterone levels do rise after repair. However, it is important for each patient to discuss the pros and cons of surgery for their particular situation.

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What are Varicoceles?

A varicocele is when veins become enlarged inside your scrotum (the pouch of skin that holds your testicles). These veins are called the pampiniform plexus. Out of 100 males, 10 to 15 have varicocele. It is like getting a varicose vein in your leg.

Varicoceles are when the pampiniform plexus veins in the scrotum become enlarged. These veins are like varicose veins (twisted, swollen veins found in the leg.) Varicoceles form during puberty. They can grow larger, and you may notice them more over time. Varicoceles are more common on the left side of the scrotum. This is because the male anatomy is not the same on both sides. Varicoceles can exist on both sides at the same time, but this is rare. About 10 to 15 boys out of 100 have a varicocele.

Most of the time, varicoceles cause no problems and are harmless. Less often varicoceles can cause pain, problems fathering a child or one testicle to grow slower or shrink.

What Happens Normally?

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The male reproductive system makes, stores and moves sperm. The scrotum is the sac of skin that holds the testicles (testes). Sperm and the hormone testosterone are made in the testicles. Sperm mature while moving through a coiled tube (the epididymis) behind each testicle.

Sperm travel to the prostate from each epididymis through a tube called the vas deferens. When you ejaculate, seminal fluid mixes with sperm in the prostate to form semen. The semen travels through the urethra and comes out the end of your penis.

The spermatic cord holds the vas deferens and the testicular artery, which brings blood to the testicle. It also houses the pampiniform plexus, a group of veins that drain the blood from the testicles. Testes need a certain body heat that is below our core body heat for optimal sperm production, maturity and function. The body heat in the scrotum is about five degrees lower than that of the belly or pelvis. The latter is due to the presence of pampiniform plexus, which act as a countercurrent heat exchanger, cooling blood in the testicular artery before it enters the testicles. This helps keep the testes at the body heat needed to make good quality sperms. When these veins become enlarged such as in varicocele, overheating of the testes can lower sperm production and function, which may affect fertility.

Diagram of the Male Reproductive Organs

Most males with a varicocele have no symptoms. But varicoceles are a concern for many reasons. Some may cause infertility (problems fathering a child) and slow growth of the left testicle during puberty. Varicoceles may be the cause of fertility problems in about four out of ten men who have problems fathering their first child. They may also be the cause of fertility problems in about eight out of ten men who have problems fathering a child after their first.

Illustration of a Varicocle

There may be many causes of varicoceles. The valves in the veins may not work well (or may be missing). If blood flow is sluggish, blood may pool in the veins. Also, the larger veins moving from the testicles towards the heart are connected differently on the left and right sides. More pressure is needed on the left side to keep blood flowing through the veins towards the heart. If blood flows backwards or pools in the veins, that can cause veins to swell. Rarely, swollen lymph nodes or other masses behind the belly block blood flow. This can lead to sudden swelling of the scrotal veins. This is often painful.

Are Varicoceles Common?

About 15 out of 100 men have varicoceles. It is hard to predict which of these 15 will have fertility problems caused by their varicocele. But about 4 in 10 men tested for fertility problems have a varicocele and decreased sperm movement. There is no link with other defects, race, place of birth or ethnic group. Though varicoceles are often found in men tested for infertility, 8 out of 10 men who have a varicocele do not have fertility problems.

Varicoceles are found through self-exam of the scrotum or during a routine doctor’s exam. They have been described as a “bag of worms” because of how they look and feel.

Urologists often check for varicoceles with the patient standing. You may be asked to take a deep breath, hold it and bear down while your urologist feels the scrotum above the testicle. This technique is known as the “Valsalva maneuver.” It lets your urologist find any enlarged veins.

Your urologist may order a scrotal ultrasound test. Ultrasound uses sound waves to make a picture of what’s inside your body. Signs of varicoceles on ultrasound are veins wider than 3 millimeters with blood flowing the wrong way during the Valsalva maneuver. The ultrasound can also show the size of the testicles. This is useful in deciding how to treat teens. An ultrasound is not needed if problems are not felt during the physical exam.

Often, varicoceles are not treated. Treatment is offered for males who have:

fertility problems (problems fathering a child)
the left testicle growing more slowly than the right
abnormal semen analysis

There are no drugs to treat or prevent varicoceles. But pain killers (such as acetaminophen or ibuprofen) may help with pain.

When needed, surgery is the main form of treatment. Embolization (briefly blocking the veins) is a non-surgical treatment option.

There are many ways to do varicocele surgery. All involve blocking the blood flow in the pampiniform plexus veins.

Surgery is done under general anesthesia. The two most common surgeries are:

Microscopic varicocelectomy: With this technique, the surgeon makes a 1 cm cut above the scrotum. Using the microscope, the surgeon ties off all small veins, but avoids the vas deferens, testicular artery and lymphatic drainage. The procedure takes 2 to 3 hours, and the patient goes home on the same day.
Laparoscopic varicocelectomy: With this technique, the surgeon inserts thin tubes in the abdomen and performs vein ligation. This procedure is shorter and takes about 30-40 minutes. Patient returns home on the same day.

Surgery Results

Since surgeons have started using smaller cuts through the muscle for open surgery, healing time and pain are about the same with microscopic and laparoscopic surgery. Problems after either surgery are rare. Some problems could include:

varicocele remaining (persistence) or coming back (recurrence)
fluid forming around the testicle (hydrocele)
injury to the testicular artery

There is a small chance surgery won't fix the problem. In rare cases, injury to the testicular artery can lead to loss of the testicle. Persistence or recurrence of the varicocele happens in less than one of ten patients who have surgery. Microscopic surgery has the lowest persistence rate or chance of varicocele coming back.

Most of the time, patients return to normal activities after one week with little pain.

Percutaneous Embolization

Embolization is done by an Interventional Radiologist. Injection of contrast through a tube with x-ray guidance is used to see the source of the problem. The goal is to find all veins leading to the varicocele. Coils (plugs with or without sclerosant, a dehydrating drug) are used to block the blood flow to the varicocele. It is done either with local anesthetic or with light sedation through a very small hole in the groin or neck. The method most often takes 45 minutes to an hour. Some problems are:

the coil moving from where it was placed
a chance of infection where the tube was placed

After Treatment

Healing after surgery is fast and pain is often mild. You should not work out for 10 to 14 days. You can often return to work 5 to 7 days after surgery. You will also follow-up with your urologist. For surgery done for fertility problems, semen analysis is done three to four months later.

Healing after embolization is also relatively short with only mild pain. You should not work out for 7 to 10 days after the procedure. You can often return to work one to two days later. The recurrence rate with embolization is on par with surgery. There are cases where embolization is preferred over surgery.

The impact of varicocele repair on fertility isn’t clear. Some studies show fertility gets better after varicocele repair while other studies don’t. Semen quality gets better in about 6 out of 10 infertile men after varicocele repair. Varicocele treatment should be considered about along with other fertility treatment choices.

In teens, where the main reason for surgery is slow testicular growth, catch-up growth may or may not happen.

Frequently Asked Questions

What will happen if i choose not to be treated.

Most males with varicocele will not have problems. One out of five males with varicocele will have trouble fathering children. Semen analysis is highly recommended after age 16 years to determine if varicocele repair is needed. If a semen analysis is normal, it is recommended to have a repeat analysis every 2 to 3 years as the quality of sperms may go down with time. Fertility issues may come up years later, even if not seen earlier.

My teenage son was diagnosed with a varicocele. Should this be fixed?

Treatment of teens depends on each case. It is of great value to talk about choices with an adult or pediatric urologist. Varicocele repair in a teen may be a good choice if there is pain, if one testicle is much smaller than the other or the teen has an abnormal semen analysis at age 16 years. Some choose repair so they won't have to worry about fertility issues in the future. Semen analyses can be done in older teens to see if repair would help.

I have no symptoms, but wish to have children. Should I have my varicocele repaired?

As a rule, varicoceles with no symptoms are not repaired. Most doctors do not believe these varicoceles cause health problems if not treated. If there's worry about fertility, semen analysis can be done to see if the varicocele is harming sperm quality.

I have pain with my varicocele. What can I do to ease the pain?

Supporting the scrotum with a jockstrap or briefs-style underwear can help varicocele pain. Lying on your back helps the varicocele drain and often eases pain. Taking pain killers (such as acetaminophen and ibuprofen) may help. You can also talk with your doctor about varicocele repair.

I am thinking about having my varicocele repaired for fertility reasons. How long will I have to wait to see if my semen quality gets better?

Semen analyses are often done three to four months after the procedure. Semen quality often gets better within six months, but it may also take as long as a year.

I found a lump on my scrotum during a self-exam. Should I worry?

Abnormalities in the male reproductive tract may show up as a mass in the scrotum. Masses could be nothing to worry about and may have little effect on your health. Or they could be a sign of life-threatening illness. It is of great value to find out what is causing your mass. One type of mass may be testicular cancer. This would be cause for concern and calls for quick action. It's vital to see a doctor when you find any lump or bump in your testicle.

Updated October 2022.

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Patient Care & Health Information
Diseases & Conditions

Your health care provider can diagnose a varicocele by visual inspection of the scrotum and by touch. You'll likely be examined while lying down and standing up.

When you're standing, your health care provider may ask you to take a deep breath, hold it and bear down, similar to the pressure during a bowel movement. This technique (Valsalva maneuver) can make a varicocele easier to examine.

Imaging test

Your health care provider may want you to have an ultrasound exam. Ultrasound uses high-frequency sound waves to create images of structures inside your body. These images may be used to:

Confirm the diagnosis or characterize the varicocele
Eliminate another condition as a possible cause of signs or symptoms
Detect a lesion or other factor obstructing blood flow
Care at Mayo Clinic

Our caring team of Mayo Clinic experts can help you with your varicocele-related health concerns Start Here

More Information

Varicocele care at Mayo Clinic

A varicocele often doesn't need to be treated. For a man experiencing infertility, surgery to correct the varicocele may be a part of the fertility treatment plan.

For teenagers or young adults — generally those not seeking fertility treatment — a health care provider may suggest annual checkups to monitor any changes. Surgery might be recommended in the following situations:

A testicle that shows delayed development
Low sperm count or other sperm irregularities (usually only tested in adults)
Chronic pain not managed by pain medication

The purpose of surgery is to seal off the affected vein to redirect the blood flow into healthy veins. This is possible because two other artery-and-vein systems supply blood circulation to and from the scrotum.

Treatment outcomes may include the following:

The affected testicle eventually may return to its expected size. In the case of a teenager, the testicle may "catch up" in development.
Sperm counts may improve, and sperm irregularities may be corrected.
Surgery may improve fertility or improve semen quality for in vitro fertilization.

Risks of surgery

Varicocele repair presents relatively few risks, which might include:

Buildup of fluid around the testicles (hydrocele)
Recurrence of varicoceles
Damage to an artery
Chronic testicular pain
Collection of blood around the testicle (hematoma)

The balance between the benefits and risks of surgery shifts if the treatment is only for pain management. While varicoceles may cause pain, most do not. A person with a varicocele may have testicular pain, but the pain may be caused by something else — an unknown or not yet identified cause. When varicocele surgery is done primarily to treat pain, there is a risk that the pain may worsen, or the nature of the pain may change.

Surgical procedures

Your surgeon can stop the flow of blood through the testicular vein by stitching or clipping the vein shut (ligation). Two approaches are commonly used today. Both require general anesthesia and are outpatient procedures that usually allow you to go home the same day. The procedures include:

Microscopic varicocelectomy. The surgeon makes a tiny incision low in the groin. Using a powerful microscope, the surgeon identifies and ligates several small veins. The procedure usually lasts 2 to 3 hours.
Laparoscopic varicocelectomy. The surgeon performs the procedure using a video camera and surgical tools attached to tubes that pass through a few very small incisions in the lower abdomen. Because the network of veins are less complex above the groin, there are fewer veins to ligate. The procedure usually last 30 to 40 minutes.

Pain from this surgery generally is mild but might continue for several days or weeks. Your doctor might prescribe pain medication for a limited period after surgery. After that, your doctor might advise you to take nonprescription pain medicine, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others) to relieve discomfort.

You'll likely be able to return to work about a week after surgery and resume exercise about two weeks after surgery. Ask your surgeon about when you can safely return to daily activities or when you can have sex.

Alternative to surgery: Embolization

In this procedure, a vein is blocked by essentially creating a tiny dam. A doctor specializing in imaging (radiologist) inserts a tiny tube into a vein in your groin or neck. A local anesthetic is used at the insertion site, and you may be given a sedative to reduce discomfort and help you relax.

Using imaging on a monitor, the tube is guided to the treatment site in the groin. The radiologist releases coils or a solution that causes scarring to create a blockage in the testicular veins. The procedure lasts about an hour.

Recovery time is short with only mild pain. You'll likely be able to return to work in 1 to 2 days and resume exercise after about a week. Ask your radiologist when you can resume all activities.

Lifestyle and home remedies

If you have a varicocele that causes minor discomfort, but doesn't affect your fertility, you might try the following for pain relief:

Take nonprescription pain medicine, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others).
Support the scrotum by wearing an athletic supporter or snug briefs.

Preparing for your appointment

A varicocele that doesn't cause pain or discomfort — which is common — may be diagnosed during a routine wellness exam. It may also be diagnosed during a more complex diagnostic process for fertility treatment.

If you're experiencing pain or discomfort in your scrotum or groin, you should be prepared to answer the following questions:

How would you describe the pain?
Where are you experiencing it?
When did it begin?
Does anything relieve the pain?
Is it constant, or does it come and go?
Have you had any injury to your groin or genitals?
What medications, dietary supplements, vitamins or herbal remedies do you take?
Ferri FF. Varicocele. In: Ferri's Clinical Advisor 2022. Elsevier; 2022. https://www.clinicalkey.com. Accessed Nov. 16, 2021.
Varicoceles. Urology Care Foundation. https://www.urologyhealth.org/urology-a-z/v/varicoceles. Accessed Nov. 16, 2021.
AskMayoExpert. Varicocele. Mayo Clinic; 2021.
Eyre RC. Nonacute scrotal conditions in adults. https://www.uptodate.com/contents/search. Accessed Nov. 16, 2021.
Zundel S, et al. Management of adolescent varicocele. Seminars in Pediatriac Surgery. 2021; doi:10.1016/j.sempedsurg.2021.151084.
Brenner JS. Causes of painless scrotal swelling in children and adolescents. https://www.uptodate.com/contents/search. Accessed Nov. 16, 2021.
Partin AW, et al., eds. Campbell-Walsh-Wein Urology. 12th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed Nov. 16, 2021.
Varicocele embolization. Radiological Society of North America. https://www.radiologyinfo.org/en/info/varicocele. Accessed Nov. 30, 2021.
Jensen NA. Allscripts EPSi. Mayo Clinic. Nov. 1, 2021.
Sevann H (expert opinion). Mayo Clinic. Dec. 12, 2021.

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Peer reviewed by Dr Hayley Willacy, FRCGP Last updated by Dr Colin Tidy, MRCGP Last updated 12 Oct 2022

Meets Patient’s editorial guidelines

In this series: Scrotal lumps, pain and swelling Testicular torsion Epididymo-orchitis Epididymal cyst Hydrocele in adults Hydrocele in children

A varicocele is like varicose veins of the small veins (blood vessels) next to one testicle (testis) or both testicles (testes).

Cross-section diagram of testicle

A varicocele is a collection of enlarged (dilated) veins (blood vessels) in the scrotum. It occurs next to and above one testicle (testis) or both testes (testicles) . Varicoceles affect the veins that travel in the spermatic cord. The spermatic cord is like a tube that goes from each testis up towards the lower tummy (abdomen). You can feel the spermatic cord above each testis in the upper side of the scrotum. The spermatic cord contains the tube that carries sperm from the testes to the penis (the vas deferens), blood vessels, lymphatic vessels and nerves. Normally, you cannot see or feel the veins in the spermatic cord that carry the blood from the testicles. If you have a varicocele, the veins become bigger (they dilate) and this makes them more noticeable. It is similar to varicose veins of the legs. The size of a varicocele can vary. A large varicocele is sometimes said to look and feel like a bag of worms in the scrotum.

Venous valve diagram

In most cases, the reason why the veins (blood vessels) become larger is because the valves of the small veins in the scrotum do not function well. There are one-way valves at intervals along the veins. The valves open to allow blood to flow towards the heart, but close when blood flow slows to stop blood flowing backwards. If these valves do not work well, blood can flow backwards (due to gravity) and pool in the lower parts of the vein to form a varicocele. (This is similar to how varicose veins form in legs.) It is not clear why the valves do not work well.

Abnormal vein valves

A varicocele may (rarely) develop if there is a blockage of larger veins higher in the tummy (abdomen). This puts back-pressure on the smaller veins in the scrotum which then enlarge (dilate). This is only likely to occur in men older than 40. For example, if a varicocele suddenly develops in an older man, it may indicate a tumour of the kidney has developed which is pressing on veins. It must be stressed, the vast majority of varicoceles develop in teenagers and young men and are not due to a serious condition.

The diagnosis is made by a doctor's physical examination. A colour duplex ultrasound scan (a scan using ultrasound to look at blood flow in an area) is sometimes done to confirm the diagnosis.

A varicocele is associated with some cases of infertility. Therefore, a semen test may be asked for if you are part of a couple being investigated for infertility.

In the rare situation of a varicocele first developing in a man aged over 40, tests to check out a possible underlying cause may be advised. Also, a solitary right-sided varicocele is unusual. If this occurs, you may need some tests to rule out any unusual cause.

See also the separate leaflet on Scrotal Lumps, Pain and Swelling (Hydrocele, Varicocele, Testicular Torsion) .

If a varicocele is causing no symptoms or problems, then it is best left alone. It is usually harmless but there are some situations in which it can cause concern.

Possible cause of infertility

Studies have shown that there is a higher percentage of infertile men with a varicocele compared with those who do not have a varicocele. The reason for this is not clear. One theory is that the pooled blood causes a slightly higher temperature in the scrotum than normal. This may reduce the number and quality of sperm production made by the testicle (testis), which can affect fertility. Even if you have a varicocele only on one side, both testicles (testes) can be warmed by the increased amount of blood pooled in the enlarged veins (blood vessels).

Research has shown that treating a varicocele usually improves sperm quality. However, most men with a varicocele are not infertile.

Currently it's recommended that a varicocele should be treated if:

It's obvious on examination (as opposed to just showing up on a scan).

Sperm count is low; you've been infertile for two years or more.

Your infertility is otherwise unexplained.

Small testis

If a large varicocele develops in a teenager, the testis on the side of the varicocele may not develop as much as would be expected. For example, an annual measurement of the testes may be advised. The testis may end up being smaller than normal. This may contribute to infertility too.

Sudden onset of a varicocele in an older man

Very rarely, a varicocele quickly develops as a symptom of a blockage of a larger vein in the tummy (abdomen) - see above. This would normally only occur in men over the age of 40.

If there is just mild discomfort, supportive underpants (rather than boxer shorts) may help to ease or prevent discomfort.

It is advised that you should be referred to a urology specialist if:

A varicocele appears suddenly and is painful (urgent referral).

The varicocele does not drain when lying down.

There is pain or discomfort.

Adolescents with a varicocele should be referred to a urologist:

If there are concerns about the testis on that side being small.

If there is uncertainty about the nature of the scrotal swelling.

If you are concerned by the appearance or symptoms.

It is not recommended that the male partner of an infertile couple be referred for varicocele surgery as a form of fertility treatment, as it does not improve pregnancy rates.

Treatment involves tying off the veins (blood vessels) that are enlarged. Another method of treatment is to use a special substance injected into the veins to block them. Both methods are usually successful. Your surgeon will advise on the pros and cons of the different techniques.

However, after successful treatment, some men have a return (recurrence) of a varicocele months or years later. This is because the veins left behind to do the job of taking the blood from the testes may themselves enlarge (dilate) with the extra blood they will now have to carry. A recurrence can be treated in the same way as the first time.

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Next review due: 11 Oct 2027

12 oct 2022 | latest version.

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Citation, DOI, disclosures and article data

At the time the article was created Donna D'Souza had no recorded disclosures.

At the time the article was last revised Calum Worsley had no financial relationships to ineligible companies to disclose.

Varicocoele
Varicoceles
Scrotal varicocele
Scrotal varicoceles
Scrotal varicocoeles
Scrotal varicocoele
Varicocoeles

Varicocele is the dilatation of the pampiniform plexus of veins, a network of many small veins found in the male spermatic cord . It is the most frequently encountered mass of the spermatic cord.

The pampiniform veins normally act as heat exchangers, important in the thermoregulation of the testes which is vital for spermatogenesis. A varicocele disturbs this balance and causes heating up of the testis to the normal core body temperature (37ºC), whereas they are normally maintained at 35ºC.

A varicocele can be classified as primary or secondary.

Primary varicocele

Most varicoceles are primary and result from incompetent or congenitally absent valves in the testicular vein (internal spermatic vein).

The left testis is affected much more commonly (≈85%) than the right. This may be due to the shorter course of the right testicular vein and its oblique insertion into the IVC which creates less backpressure. In contrast, the left testicular vein has a longer course and inserts into the left renal vein at a right angle. Bilateral varicoceles are not uncommon (≈15%), but isolated right varicoceles are rare and should prompt evaluation for a secondary varicocele.

Secondary varicocele

Secondary varicoceles are much less common and result from increased pressure in the testicular vein due to compression (e.g. extrinsic mass such as retroperitoneal lymphadenopathy or renal mass, or renal vein compression in nutcracker syndrome 9 ), obstruction (e.g. renal vein thrombus ), or splenorenal shunting ( portal hypertension ).

intratesticular varicocele

The diagnostic modality of choice:

dilatation of pampiniform plexus veins >2-3 mm in diameter 3,4

characteristically have a serpiginous appearance

there can be flow reversal with the Valsalva maneuver 4

Doppler ultrasound can be used to grade the degree of reflux

may show a dilated cluster of enhancing serpiginous veins

Angiography (DSA)

Venography, only performed during endovascular treatment, may demonstrate:

dilated testicular veins

retrograde flow of contrast towards the scrotum

dilated pampiniform plexus should not be directly imaged as the testes should be kept out of the x-ray beam

may be incidentally noted during scrotal MRI

dilated enhancing serpiginous veins

signal intensity depends on the velocity of flow

low flow: intermediate T1 and high T2

high flow: signal void

enhancement following gadolinium administration

This is one of the surgically correctable causes of male infertility . Management options include:

embolization of the testicular vein

surgical ligation of the testicular vein

A unilateral right-sided varicocele is an uncommon finding and, if found, should prompt an evaluation of the retroperitoneum to exclude a mass obstructing the downstream testicular vein.

1. Woodward PJ, Schwab CM, Sesterhenn IA. From the archives of the AFIP: extratesticular scrotal masses: radiologic-pathologic correlation. Radiographics. 23 (1): 215-40. doi:10.1148/rg.231025133 - Pubmed citation
2. Bhosale PR, Patnana M, Viswanathan C et-al. The inguinal canal: anatomy and imaging features of common and uncommon masses. Radiographics. 28 (3): 819-35. doi:10.1148/rg.283075110 - Pubmed citation
3. Chiou RK, Anderson JC, Wobig RK et-al. Color Doppler ultrasound criteria to diagnose varicoceles: correlation of a new scoring system with physical examination. Urology. 1997;50 (6): 953-6. doi:10.1016/S0090-4295(97)00452-4 - Pubmed citation
4. Lee J, Binsaleh S, Lo K et-al. Varicoceles: the diagnostic dilemma. J. Androl. 2007;29 (2): 143-6. doi:10.2164/jandrol.107.003467 - Pubmed citation
5. Vanlangenhove P, Dhondt E, Van Maele G, Van Waesberghe S, Delanghe E, Defreyne L. Internal Spermatic Vein Insufficiency in Varicoceles: A Different Entity in Adults and Adolescents?. AJR. American journal of roentgenology. 205 (3): 667-75. doi:10.2214/AJR.14.14085 - Pubmed
6. Lorenc T, Krupniewski L, Palczewski P, Gołębiowski M. The value of ultrasonography in the diagnosis of varicocele. (2016) Journal of ultrasonography. 16 (67): 359-370. doi:10.15557/JoU.2016.0036 - Pubmed
7. de Los Reyes T, Locke J, Afshar K. Varicoceles in the pediatric population: Diagnosis, treatment, and outcomes. (2017) Canadian Urological Association journal = Journal de l'Association des urologues du Canada. 11 (1-2Suppl1): S34-S39. doi:10.5489/cuaj.4340 - Pubmed
8. Gleason A, Bishop K, Xi Y, Fetzer D. Isolated Right-Sided Varicocele: Is Further Workup Necessary? AJR Am J Roentgenol. 2019;212(4):802-7. doi:10.2214/ajr.18.20077 - Pubmed
9. Hind G & Najwa B. Left Varicocele Revealing a Nutcracker Phenomenon. Pan Afr Med J. 2021;39:131. doi:10.11604/pamj.2021.39.131.29964 - Pubmed

Incoming Links

Thrombosis of the pampiniform plexus
Paratesticular lesions
Bähren classification of left varicoceles
Intratesticular varicocele
Varicocele grading on colour Doppler
Varicocele embolisation
Pampiniform plexus
Pelvic congestion syndrome
Extratesticular cystic lesions (differential)
Bilobed testis
Azoospermia
Valsalva manoeuvre
Gonadal vein
Scrotal haematocele
Polyorchidism
Inguinal hernia
Urogenital curriculum
Nutcracker syndrome
Atrophic testis
Testicular varicocele (paediatric)
Epididymo-orchitis - acute
Left renal carcinoma (T3a) with varicocele
Testicular multifocal seminoma
Torsion of the appendix epididymis
Varicocele - grade 4
Paratesticular alveolar rhabdomyosarcoma
Retroperitoneal sarcoma presenting as a right-sided varicocele

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Introduction

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]

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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 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]

Epidemiology

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]

Pathophysiology

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] (A1)

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. (B3)

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] (A1)

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. (A1)

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] (A1)

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. (A1)

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] (A1)

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] (B2)

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] (B3)

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. (A1)

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] (B2)

Differential Diagnosis

A broad differential diagnosis for varicocele includes the following:

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

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.

Complications

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.

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Division of Urology

What is a varicocele.

All boys have veins in the scrotum that take blood from the testicles up towards the heart. The blood that is slow to return to the heart can collect in the veins, which then causes the veins to get bigger, or become swollen. When this happens in the scrotum it is called a varicocele.

Although they don't happen to every boy, varicoceles are fairly common. About 17 percent of boys between the ages of 13-25 years old have varicoceles. More than 90 percent of the time, they appear on the left testicle and they mostly occur during or after puberty. That's because during puberty, the testicles grow rapidly and need more blood delivered to them. Although most of the blood continues to flow correctly, blood can begin to back up, creating a varicocele.

Signs and symptoms

In most cases, boys have no symptoms at all and might not even know they have a varicocele. Usually, a varicocele is noticed by a doctor during a testicular exam.

The veins will feel like a “bag of worms” while your child is standing and may disappear while he is lying down.

Sometimes after heavy exercise, hot weather, or standing for a long time, your child may feel a heaviness or dull discomfort in his scrotum.

Testing and diagnosis

At the Division of Urology , your child's urologist will order a scrotal ultrasound, a painless test that will take pictures and measure the size of each testicle. We will compare the size of the left and right testicle to make sure they are equal. As your child continues to go through puberty and adolescence, we will order additional ultrasounds to make sure the testicles continue to grow equally.

Surgery is only indicated when a size difference between the left and right testicles is larger than 20 percent, based on several ultrasounds.

Once your child reaches 18 years old, we will offer the option of a semen analysis. If sperm count is low on repeated specimens, surgery may be indicated.

Through continued research at CHOP, we have shown that as boys go through puberty, the testicles may grow at different rates. If a size discrepancy is evident, we will ask that the ultrasound be repeated before deciding to go through with surgery.

Reviewed by : Division of Urology

Providers Who Treat Varicocele

Thomas F. Kolon, MD

Sameer Mittal, MD, MSc

Aseem R. Shukla, MD, MHCI

Arun K. Srinivasan, MD, MRCS

Gregory E. Tasian, MD, MSc, MSCE

Jason Van Batavia, MD, MSTR

Mark R. Zaontz, MD

Your Child's Urology Surgery

Find information to help you prepare for your child's upcoming urology surgery at Children's Hospital of Philadelphia.

Why Choose Us

The Division of Urology at Children’s Hospital of Philadelphia is consistently ranked as one of the top pediatric urology programs in the nation.

Reference work entry
First Online: 28 May 2023
Cite this reference work entry

Jason P. van Batavia 3 &
Kenneth I. Glassberg 2

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Scrotal varicocele is a common finding in adolescent boys and a common reason for referral to the pediatric urologist. While uncommon in prepubertal boys, the prevalence of varicocele increases during adolescence to approach the ~15% incidence rate noted in adult men. In fact, population studies have estimated the incidence of adolescent varicocele to be between 8% and 16%, with one large screening study reporting an incidence of 29% in boys aged 10–16 years old. While an asymptomatic varicocele may seem to be of little to no concern, the fact that 20% of men with varicoceles have problems with fertility is concerning, but predicting which adolescents will become part of this 20% is complex. The use of semen analysis offers an objective way to assess patients with varicoceles, but an “abnormal” semen analysis (SA) does not guarantee infertility in much the same way that a normal SA does not guarantee fertility. Furthermore, obtaining SA in adolescents can be difficult. Therefore, surrogate indications for varicocele repair have been suggested over the previous couple of decades to help guide the pediatric surgeon/urologist in management. If varicocele repair is indicated and the patient and family decide to proceed, there are several procedures and techniques available to the surgeon including surgical repair via retroperitoneal approach, inguinal approach, subinguinal microscopy, laparoscopy, and nonsurgical techniques such as percutaneous sclerotherapy and angiography with embolization. Regardless of the technique used, the ultimate goal of varicocele correction is future paternity, which unfortunately is difficult to study and not often commented upon in the literature.

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Management of Pediatric and Adolescent Varicocele

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van Batavia, J.P., Glassberg, K.I. (2023). Varicocele. In: Puri, P. (eds) Pediatric Surgery. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-43567-0_195

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Clin Case Rep
v.10(11); 2022 Nov

Acute left side varicocele as primary presentation of renal cell carcinoma

Asaad moradi.

1 Department of urology, Firoozgar Hospital, School of Medicine, Iran University of Medical Sciences, Tehran Iran

Behnam Shakiba

Associated data.

A 68‐year‐old man was referred with acute left side varicocele scrotum. Abdominal computed tomography showed a mass lesion in left kidney. The patient underwent radical nephrectomy. Microscopic histopathology confirmed the diagnosis of renal cell carcinoma. The majority of varicocele have a non‐pathological etiology but acute varicocele may indicate retroperitoneal mass.

Short abstract

Although the majority of varicocele have a non‐pathological etiology, acute nontraumatic varicocele especially in older patients and tense varicocele in supine position may indicate the presence of a retroperitoneal mass especially renal cell carcinoma.

A 68‐year‐old Iranian man was referred to our clinic with varicose veins had developed in his left hemi scrotum 2 months earlier. He had no history of hematuria or flank pain. On physical examination, an enlarged varicose vein was visible in the left spermatic cord (Figure 1 , arrow). Abdominal computed tomography showed an enhancing mass lesion measuring 10 × 12 × 11 cm in left kidney (Figure 2 , arrow). With the clinical diagnosis of renal cell carcinoma, patient underwent left side open radical nephrectomy. The operation was uneventful, and the patient was discharged after 4 days with no complications. Microscopic histopathology confirmed the diagnosis of clear renal cell carcinoma. Tumor extends into the renal vein and renal sinus fat (pT3a). Due to lung metastasis, he was referred for sunitinib therapy; unfortunately, he died some months after operation.

An external file that holds a picture, illustration, etc.
Object name is CCR3-10-e6514-g002.jpg

On physical examination, an enlarged varicose vein was visible in the left spermatic cord

An external file that holds a picture, illustration, etc.
Object name is CCR3-10-e6514-g001.jpg

Abdominal computed tomography showed an enhancing mass lesion in left kidney

Varicocele, which is defined as an abnormal venous dilatation and tortuosity of the pampiniform plexus, occurs more commonly on the left side. 1 Although the majority of varicocele have a non‐pathological etiology, acute nontraumatic varicocele especially in older patients and tense varicocele in supine position may indicate the presence of a retroperitoneal mass especially renal cell carcinoma. 2 Other causes include retroperitoneal sarcoma, retroperitoneal fibrosis, and lymphoma. 3

AUTHOR CONTRIBUTIONS

Behnam Shakiba involved in conceptualization. Asaad Moradi involved in writing–original draft preparation. Behnam Shakiba involved in writing–review and editing. All authors have read and approved the final version of the manuscript.

CONFLICT OF INTEREST

Ethical approval.

All procedures performed were in accordance with the ethical standards.

Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy

ACKNOWLEDGMENT

Present study was supported by Firoozgar Clinical Research Development Center, Iran University of Medical Sciences, Tehran, Iran.

Moradi A, Shakiba B. Acute left side varicocele as primary presentation of renal cell carcinoma . Clin Case Rep . 2022; 10 :e06514. doi: 10.1002/ccr3.6514 [ CrossRef ] [ Google Scholar ]

DATA AVAILABILITY STATEMENT

IMAGES

Varicocele
Varicocele Embolization
VARICOSE VEINS Clinical case presentation
Varicocele Diagram
Diagrammatic representation of varicocele
PPT

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VARICOCELE CLINICAL CASE 4
Varicocele and Infertility- Do you need operation?
A revision microsurgery for Varicocele repair
Case Presentation
UROLOGY SURGERY lecture 16 VARICOCELE all aspects covered with important points
Who Should Get Varicocele Embolisation Treatment?

COMMENTS

Varicocele
Varicocele is a common condition that affects the veins of the scrotum and can impair male fertility and testicular growth. This NCBI Bookshelf chapter provides an overview of the causes, diagnosis, treatment, and complications of varicocele, based on the latest evidence and guidelines. Learn more about this important men's health issue by clicking on the link.
Varicocele
Possible signs and symptoms may include: Pain. A dull, aching pain or discomfort is more likely when standing or late in the day. Lying down often relieves pain. A mass in the scrotum. If a varicocele is large enough, a mass like a "bag of worms" may be visible above the testicle. A smaller varicocele may be too small to see but noticeable by ...
Men's Health: The Varicocele: Clinical Presentation, Evaluation, and
A varicocele is an abnormal dilatation and tortuosity of the veins of the spermatic cord. It is a common condition among men of all ages, affecting approximately 15% of the male population. 1 In addition, as the most common correctable cause of male infertility, it affects 19 to 41% of men with primary infertility and 45 to 81% of men with ...
Varicocele: Causes, Symptoms, Diagnosis & Treatment
Varicocele. Varicoceles are swollen veins in your scrotum. They usually cause mild symptoms, including scrotal swelling or aching pain in your testicle. They may not cause any symptoms at all. However, they're a common cause of infertility. A healthcare provider can diagnose a varicocele and recommend the proper treatment.
Varicocele
Request an Appointment. 410-955-5000 Maryland. 855-695-4872 Outside of Maryland. +1-410-502-7683 International. Varicocele is a term used to describe abnormally dilated veins (called the "pampiniform plexus" of veins) in the scrotum.
Varicoceles: Symptoms, Diagnosis & Treatment
A varicocele is when veins become enlarged inside your scrotum (the pouch of skin that holds your testicles). These veins are called the pampiniform plexus. Out of 100 males, 10 to 15 have varicocele. It is like getting a varicose vein in your leg. Varicoceles are when the pampiniform plexus veins in the scrotum become enlarged.
Varicocele
While varicoceles may cause pain, most do not. A person with a varicocele may have testicular pain, but the pain may be caused by something else — an unknown or not yet identified cause. When varicocele surgery is done primarily to treat pain, there is a risk that the pain may worsen, or the nature of the pain may change. Surgical procedures
Varicocele: Practice Essentials, History of the Procedure ...
Varicocele is a well-recognized cause of decreased testicular function and occurs in approximately 15-20% of all males and in 40% of infertile males. ... In a prospective study of men with a mean follow-up of 5 years, among men with an abnormal semen analysis at presentation, the quality of semen degenerated in 28 subjects (87.5%); however, but ...
Varicocele management for infertility and pain: A systematic review
Clinical presentation. Varicoceles are commonly identified in one of three presentations. First, young males presenting for routine examination are noted to have an asymptomatic varicocele on physical examination. Second, men of reproductive age note difficulty with conception and present to their fertility specialist with a history of primary ...
Varicocele: Causes, Symptoms, and Treatment
A varicocele is a collection of enlarged (dilated) veins (blood vessels) in the scrotum. It occurs next to and above one testicle (testis) or both testes (testicles). Varicoceles affect the veins that travel in the spermatic cord. The spermatic cord is like a tube that goes from each testis up towards the lower tummy (abdomen).
Varicocele
Varicoceles are rare in children under the age of ten years. However, they may be seen in up to 15-20% of adolescents and young men, as high as 42% in elderly men 7,8. Clinical presentation. Varicoceles can be asymptomatic. If symptomatic, presentations include: scrotal mass/swelling. scrotal pain. testicular atrophy. infertility or ...
Varicocele in Adolescents Clinical Presentation
The vast majority of adolescents with varicoceles are asymptomatic. The diagnosis is made by carefully palpating the scrotum during a thorough upright physical examination. The patient is examined in the standing position, and the scrotum is visually inspected for distended veins, which can usually be seen on the lateral aspect of the scrotum.
Varicocele Clinical Diagnosis and Grading
Clinical diagnosis of varicocele depends upon clinical presentation and physical examination and may be aided by radiological investigations. Generally, varicocele is asymptomatic and is only accidentally discovered during the physical examination of infertile men, athletes, or army recruits. However, varicocele may present with dull aching ...
Varicocele
The classical presentations of varicocele include infertility, scrotal pain, decreased testicular volume or scrotal swelling. Other causes of male infertility should be assessed and managed. Exclusion of female factor infertility is an essential step in evaluation of varicocele patients presenting with infertility. The classical scrotal pain is ...
Varicocele
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 ...
Varicocele
The blood that is slow to return to the heart can collect in the veins, which then causes the veins to get bigger, or become swollen. When this happens in the scrotum it is called a varicocele. Although they don't happen to every boy, varicoceles are fairly common. About 17 percent of boys between the ages of 13-25 years old have varicoceles.
Varicocele Embolization: Patient Selection: Preprocedure Workup, and
Varicocele refers to an abnormally dilated and tortuous pampiniform venous plexus within the spermatic cord. The prevalence of varicocele is reported to be approximately 15% in the general male population. Its incidence increases with age and has a higher incidence in infertile men. ... The most common clinical presentation of varicoceles in ...
The Varicocele: Clinical Presentation, Evaluation, and Surgical
A varicocele is an abnormal dilatation and tortuosity of the veins of the spermatic cord. Although varicoceles are common in the general population and are frequently found on routine physical ...
Varicocele
Scrotal varicocele is a common finding in adolescent boys and a common reason for referral to the pediatric urologist. While uncommon in prepubertal boys, the prevalence of varicocele increases during adolescence to approach the ~15% incidence rate noted in adult men. In fact, population studies have estimated the incidence of adolescent ...
Image-Guided Treatment of Varicoceles: A Brief Literature Review and
Treatment of varicocele should be considered when the female partner has normal or correctable fertility status and sperm analysis reveals an abnormality. 12 Varicocele repair carries the potential benefit of correcting the underlying pathology of infertility in a cost-effective way for well-selected patients. 13 14 Other factors that should be ...
Varicocele
Varicocele - Download as a PDF or view online for free. Varicocele - Download as a PDF or view online for free ... Conclusion: The presentation concludes with findings supporting the effectiveness of checklist-based nursing care in CTO interventions, suggesting improvements in patient care processes and outcomes. The study highlights the ...
Acute left side varicocele as primary presentation of renal cell
Varicocele, which is defined as an abnormal venous dilatation and tortuosity of the pampiniform plexus, occurs more commonly on the left side. 1 Although the majority of varicocele have a non‐pathological etiology, acute nontraumatic varicocele especially in older patients and tense varicocele in supine position may indicate the presence of a ...