Varicoceles are enlarged veins in the scrotum. They are similar to varicose veins usually experienced in the legs and affect about 15-20% of men. They can cause mild symptoms like aching pain or swelling, but many people have no symptoms at all. They can affect fertility, contributing to around 40% of male infertility cases. You may be aware of your varicocele but not realise it is affecting your fertility until you try to have children. Scrotal varicoceles have been known to cause low testosterone (male hypogonadism) and azoospermia, where there is no sperm in the semen.
Diagnosis is usually through a physical exam, blood tests, semen analysis and/or ultrasound. Diagnoses are graded based on size and palpability of the varicocele. Treatment options range from supportive measures and medications, to surgery (varicocelectomy) if there is significant pain or fertility is affected. Varicocele surgery can improve fertility in some cases.
Overview
- A varicocele is an enlargement of veins within the scrotal sac, similar to varicose veins, affecting blood drainage from the testicles.
- Often without symptoms, but it may cause swelling and/or a dull ache in the scrotum and could be linked to infertility.
- Prevalence: affects about 15–20% of men.
- More common on the left side due to anatomical drainage differences.
Symptoms & Causes
Symptoms
- Dull, aching pain, especially after standing or physical activity
- Scrotal heaviness or swelling
- Testicular atrophy (shrinking)
- “Bag of worms” feeling in the scrotum
- Infertility or difficulty conceiving
Possible Causes / Mechanism
- Faulty valves in the veins of the scrotum causing blood to collect, enlarging the veins
- This can lead to increased scrotal temperature which may impair sperm function
Diagnosis & Evaluation
- Physical examination: visual inspection and feeling with the fingers in a standing and lying position, often with specific breathing instructions to be able to detect the varicocele better.
- Ultrasound of the scrotum is used to confirm diagnosis, assess vein dilation, and exclude other causes
Treatment & Management
Conservative / Monitoring
- If without symptoms and fertility is not a concern, watchful waiting is an option
- Pain management with oral pain medication
- Lifestyle measures (e.g., avoiding prolonged standing)
Surgical / Interventional Treatment
- Varicocelectomy: surgical tying off of affected veins
- Commonly done via minimally invasive microsurgery for better fertility outcomes and fewer complications
- Success rates: 26–40% achieve spontaneous pregnancy post-surgery; up to 90% report symptom improvement when surgery is for pain
- Alternative techniques: blockage of the blood vessel or laparoscopic repair in selected cases
- Risks / Considerations: recurrence, surgical risks, worsening pain in rare cases
Takeaway
Varicoceles are a frequent, often silent condition of enlarged scrotal veins that can contribute to male infertility and testicular dysfunction. While many men require no intervention, in cases of pain or fertility concerns, microsurgical repair has proven effective when carefully applied. Timely diagnosis, appropriate patient selection, and expert surgical technique are key to optimising outcomes.
Read this article by The Cleveland Clinic to find out more about varicoceles and what questions to ask your healthcare provider to get support if you think you have a varicocele.
