Varicocele of the Testicles

Why varicoceles form

Blood drains from each testicle through a network of veins (the pampiniform plexus) into the testicular vein. Valves in the veins keep blood flowing toward the heart. When the valves fail, blood pools and the veins enlarge. The left testicular vein is longer and joins the left kidney vein at a right angle, so pressure is higher on the left, explaining why most varicoceles are left-sided.

Rarely, a tumor or mass in the abdomen, such as a kidney cancer, compresses the veins and causes a varicocele that appears suddenly, especially in older men or on the right side.

How varicoceles affect fertility

Pooled blood raises the temperature around the testicle and may cause oxidative stress, which can lower sperm count, movement and shape and damage sperm DNA. Over time it can reduce testicle size and, in some men, testosterone production. Many men with varicoceles have normal fertility. See male factor infertility.

Symptoms

• often no symptoms
• dull ache or heaviness in the scrotum, worse after standing, exercise or heat, relieved by lying down
• a soft lump above the testicle that feels like a "bag of worms"
• visible swollen veins in large varicoceles
• a smaller testicle on the affected side
• infertility

Grades

Diagnosis

A doctor examines the scrotum while you stand, and while you bear down or cough, and then lying down, where a varicocele typically shrinks. Testicle size is measured. Scrotal ultrasound with Doppler confirms enlarged veins and reflux of blood and measures testicular volume. Semen analysis is done for men with fertility concerns, and hormone tests if testosterone deficiency is suspected. An abdominal ultrasound or CT is done for new right-sided or non-shrinking varicoceles.

Varicocele vs other scrotal swellings

Treatment

When treatment is recommended

• persistent pain or discomfort
• infertility with an abnormal semen analysis and a varicocele that can be felt
• a testicle shrinking in a teenager (for example, one testicle more than about 20 percent smaller) or abnormal semen parameters in young men
• low testosterone in some men

Small, painless varicoceles in men with normal testicles and no fertility concerns do not need treatment.

Conservative measures

Supportive underwear or an athletic supporter, avoiding prolonged standing, and over-the-counter pain relievers at the label dose for occasional aching.

Procedures

• Microsurgical varicocelectomy: through a small groin incision under an operating microscope, the surgeon ties off the abnormal veins while preserving arteries and lymph vessels. It has the lowest recurrence and complication rates.
• Laparoscopic varicocelectomy: keyhole surgery through the abdomen.
• Percutaneous embolization: a radiologist blocks the abnormal vein with coils or a sclerosing agent through a catheter inserted in a vein; no incision in the scrotum or groin.

Complications are uncommon and include recurrence, hydrocele and, rarely, testicular injury. After repair, semen quality often improves over 3 to 6 months, and pregnancy rates increase in couples where the man had a palpable varicocele and abnormal semen.

Frequently asked questions

Is a varicocele serious?

Usually not. Many varicoceles cause no problems and need no treatment. They can cause aching, a smaller testicle or reduced fertility in some men. A varicocele that appears suddenly in an older man or only on the right side should be checked for an underlying cause.

Does a varicocele cause infertility?

It can. Varicoceles are found in about 35 to 40 percent of men with infertility and can lower sperm count and quality. However, many men with varicoceles father children without difficulty. Repair improves semen quality and pregnancy chances in selected men.

Can a varicocele go away on its own?

Varicoceles do not usually go away on their own, but many stay stable and cause no problems for life. Treatment is only needed for pain, fertility problems or testicular shrinkage.

What does a varicocele feel like?

It often feels like a soft "bag of worms" above the testicle, more noticeable when standing and smaller when lying down. Some men feel a dull ache or heaviness, especially after standing for a long time, exercising or in hot weather.