Varicocele

Overview

A varicocele is an abnormal dilation (enlargement) of the veins within the scrotum that drain blood from the testicle — specifically the pampiniform venous plexus. It is analogous to varicose veins in the legs, caused by incompetent venous valves that allow blood to pool rather than return efficiently to the circulation.

Varicoceles are common, present in approximately 15% of adult men in the general population. They are found in around 35–40% of men presenting for investigation of male factor infertility, suggesting an association with impaired testicular function, though many men with varicocele have normal fertility.

Varicoceles are graded clinically:

• Grade I — palpable only on Valsalva manoeuvre (bearing down)
• Grade II — palpable without Valsalva but not visible
• Grade III — visible through the scrotal skin (bag of worms appearance)

The large majority (approximately 90%) occur on the left side, because the left testicular vein drains at a right angle into the left renal vein — a configuration that predisposes to increased pressure and valve failure. Right-sided or bilateral varicoceles can occur but should prompt investigation for secondary causes (such as a retroperitoneal mass) when they appear in isolation on the right.

Symptoms

Many varicoceles cause no symptoms and are found incidentally — during a fertility investigation or a routine examination. When symptoms are present, they include:

• Scrotal ache or heaviness — typically a dull, dragging discomfort, often worsening after prolonged standing, physical exertion, or at the end of the day; relieved by lying down
• Visible or palpable scrotal swelling — a characteristic “bag of worms” texture on palpation above and behind the testicle
• Testicular atrophy — the affected testicle may be smaller, particularly in adolescents where varicocele can impair testicular development

Diagnosis

• Clinical examination — standing examination of the scrotum is performed at rest and during Valsalva to grade the varicocele
• Scrotal duplex ultrasound — confirms the diagnosis, measures the diameter of the dilated veins, assesses testicular volume on both sides, and documents blood flow reversal during Valsalva; also excludes any testicular pathology
• Semen analysis — essential when infertility is a concern; assesses sperm concentration, motility, and morphology
• Hormone profile — FSH, LH, and testosterone may be measured if there is concern about testicular function

Treatment

Indications for treatment

• Significant symptomatic scrotal pain affecting quality of life
• Infertility with documented abnormal semen parameters and a clinically palpable varicocele
• Adolescents with progressive testicular growth arrest on the affected side

Surgical ligation The standard surgical approach involves identification and ligation of the dilated testicular veins through a small incision. The subinguinal microsurgical approach — performed with loupes or an operating microscope — is the technique associated with the lowest recurrence and complication rates. It allows precise identification of veins, preservation of the testicular artery and lymphatics, and ligation of all abnormal vessels. This is a day-case procedure under general or local anaesthetic.

Percutaneous embolisation Performed by an interventional radiologist, a catheter is inserted via a vein in the groin or neck and guided to the testicular vein under X-ray screening. Small metal coils or a sclerosant agent are deployed to block the abnormal veins. The procedure is minimally invasive and is usually performed under local anaesthetic. Recovery is typically rapid.

Both approaches have comparable success rates; selection depends on clinical factors, anatomical considerations, and individual patient preference.