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Varicocele

SNOMED: 51070004628 words•Updated 03/03/2026

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Exam Tips

Classic viva line: 'left-sided bag of worms, worse on standing/Valsalva, decompresses when supine.'
Know grading: subclinical (Doppler only), grade I (Valsalva only), grade II (palpable), grade III (visible).
Urgent referral triggers: sudden painful varicocele or one that does not drain when lying down (exclude secondary obstruction).
In adolescents, surgery is mainly for testicular growth arrest/asymmetry rather than varicocele size alone.
In infertility OSCE stations, discuss semen analysis and specialist referral if clinical varicocele plus abnormal semen profile and otherwise unexplained infertility.

Definition

A varicocele is an abnormal dilatation and tortuosity of the pampiniform venous plexus within the spermatic cord, producing a scrotal swelling that is usually left-sided. It is typically due to venous valve incompetence or absent valves, and more rarely reflects secondary venous obstruction (for example by a retroperitoneal or renal pathology), so red-flag presentations must be excluded.

Pathophysiology

Varicoceles usually become apparent in adolescence as testicular blood flow rises with growth. The left side is affected in about 90% because the left internal spermatic vein is longer and drains vertically into the left renal vein at near right angles, increasing hydrostatic pressure; the right drains more obliquely into the IVC, which is relatively protective. Venous reflux and stasis in the pampiniform plexus can impair testicular function via increased scrotal temperature, relative hypoxia, and reflux of metabolites, contributing to impaired spermatogenesis, gonadotrophin abnormalities, and testicular volume loss. Bilateral disease can occur via cross-communication between plexuses.

Risk Factors

Adolescence (onset commonly during pubertal growth)
Tall, lean habitus / low BMI
Underweight state
Family history (especially first-degree relatives)

Clinical Features

Symptoms

Often asymptomatic
Painless left scrotal swelling
Scrotal heaviness or dragging discomfort (uncommon)
Subfertility or infertility concern

Signs

Classical 'bag of worms' texture above the testis on standing (see Figure: standing scrotal examination appearance)
More prominent with Valsalva and when upright
Reduces or becomes impalpable when supine
Affected hemiscrotum may hang lower
Possible ipsilateral smaller testis/testicular growth arrest in adolescents

Investigations

Clinical examination (standing and supine, with Valsalva):Grade I palpable only on Valsalva; Grade II palpable without Valsalva; Grade III visible through scrotal skin; reduction on lying supports diagnosis

Scrotal ultrasound with colour Doppler:Dilated pampiniform veins with reflux; useful when diagnosis is uncertain or examination is difficult (e. g. thick scrotal tissues)

Semen analysis (if fertility concern or clinically indicated):May show abnormal semen parameters in clinically significant varicocele

Serum FSH and testosterone:Raised FSH with abnormal sperm production suggests impaired spermatogenesis; testosterone may identify hypogonadism

Urgent specialist assessment for red flags:Sudden painful onset or failure to decompress when supine warrants exclusion of secondary obstruction (e. g. renal/retroperitoneal mass)

Management

Lifestyle Modifications

Explain benign natural history in most cases and provide reassurance
Observe adolescents with grade II-III and symmetric testes using annual testicular size review through puberty
For men with low-grade/asymptomatic disease, conservative follow-up; discuss fertility planning and when semen testing is useful
Safety-net: urgent review for sudden pain, rapid change in size, persistent non-reducing swelling, or new systemic symptoms

Pharmacological Treatment

Simple analgesic

Paracetamol 1 g orally every 4-6 hours when required (max 4 g/24 h; age 16-17 years: max 4 doses/24 h)

Use for symptomatic discomfort only; avoid exceeding total daily dose and check combination products to prevent accidental overdose. No drug therapy treats the varicocele itself.

NSAID

Ibuprofen 400 mg orally up to three times daily with food (adult/older adolescent; use lowest effective dose for shortest duration)

Avoid/seek advice in peptic ulcer disease, significant renal impairment, NSAID-exacerbated asthma, heart failure, anticoagulant use, or established cardiovascular risk; counsel on GI and renal adverse effects.

Surgical / Interventional

Microsurgical/open varicocelectomy (ligation of refluxing spermatic veins)
Laparoscopic varicocele ligation
Percutaneous embolization/sclerotherapy (interventional radiology approach)
Indications in UK-style practice: adolescent testicular growth arrest/asymmetry, symptomatic grade II-III disease, or abnormal semen parameters with specialist input rather than routine surgery solely for fertility

Complications

Chronic scrotal discomfort/pain
Ipsilateral testicular growth arrest or volume loss (and possible contralateral volume reduction later in adolescence)
Hypogonadism/testicular dysfunction
Impaired spermatogenesis and subfertility/infertility
Psychological distress related to scrotal appearance or fertility concerns

Prognosis

Most varicoceles are asymptomatic, remain stable, and do not require intervention. When surgery is indicated, pain and testicular volume often improve and semen parameters may improve, but translation to higher pregnancy rates is variable and depends on couple-level fertility factors.