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# Varicocele

A varicocele is a group of widened veins in the [scrotum](https://durgical.com/en/anatomy/scrotum/) above the [testis](https://durgical.com/en/anatomy/testis/), usually on the left; it is the most common correctable cause of male infertility.

Updated 2026-10-29

## Structures involved

Tap one to see what it is and open it in 3D.

- [Testicular veins and pampiniform plexus](https://durgical.com/en/anatomy/testicular-vein-pampiniform-plexus/)
- [Spermatic cord](https://durgical.com/en/anatomy/spermatic-cord/)
- [Testes](https://durgical.com/en/anatomy/testis/)
- [Scrotum](https://durgical.com/en/anatomy/scrotum/)
- [Epididymis](https://durgical.com/en/anatomy/epididymis/)
- [Testicular arteries](https://durgical.com/en/anatomy/testicular-artery-pelvis/)

## In histology

- [Testis: seminiferous tubules, Sertoli and Leydig cells, spermatogenesis](https://durgical.com/en/histology/testis-seminiferous-tubules-sertoli-and-leydig-cells-spermatogenesis/)

## In the clinical exam

- [Male genital exam: transillumination, cremasteric reflex, Prehn sign](https://durgical.com/en/clinical-exam/male-genital-exam-transillumination-cremasteric-reflex-prehn-sign/)

## In physiology

- [The male gonadal axis and spermatogenesis](https://durgical.com/en/physiology/the-male-gonadal-axis-and-spermatogenesis/)

## What it is

Dilated, tortuous veins of the pampiniform plexus in the [spermatic cord](https://durgical.com/en/anatomy/spermatic-cord/). Usually left-sided, it is the most common correctable cause of male infertility.

## Who gets it

Common in adolescents and adult men, and much more frequent among men evaluated for infertility. Most are on the left side.

## Causes

- Absent or incompetent valves in the testicular vein
- Left testicular vein: longer, draining at a right angle into the [left renal vein](https://durgical.com/en/anatomy/right-renal-vein/), so pressure is higher
- Compression of the left renal vein between the aorta and [superior mesenteric artery](https://durgical.com/en/anatomy/superior-mesenteric-artery/) (nutcracker phenomenon)
- Secondary: a renal or retroperitoneal mass blocking venous drainage

## Risk factors

- Adolescence and young adulthood
- Left-sided venous anatomy
- Tall, lean build (reported in some studies)
- Renal or retroperitoneal tumour (secondary varicocele)

## Pathophysiology

Venous reflux and pooling raise scrotal temperature and expose the testis to hypoxia and oxidative stress. This impairs sperm production and, in adolescents, can slow testicular growth.

## Classification

- Subclinical: seen only on ultrasound
- Grade 1: palpable only with Valsalva
- Grade 2: palpable standing, without Valsalva
- Grade 3: visible through the scrotal [skin](https://durgical.com/en/anatomy/skin/)
- Primary or secondary (to compression of venous drainage)

## Symptoms and signs

- Often none
- Dull ache or heaviness, worse standing or late in the day, better lying down
- Soft mass above the testis that feels like a «bag of worms», more obvious with Valsalva
- Smaller testis on the affected side in adolescents
- Infertility or abnormal semen analysis

## Red flags

- Isolated right-sided varicocele
- Varicocele that does not collapse lying down
- Sudden onset in an older man (consider a renal or retroperitoneal mass)

## Diagnosis

**Clinical**
Examination standing and lying, with and without Valsalva, and clinical grading.

**Tests**
Semen analysis in adults with fertility concerns; FSH and testosterone in selected cases.

**Imaging**
Scrotal colour Doppler ultrasound confirms dilated veins and reflux and measures testicular volume; abdominal imaging for right-sided or non-collapsing varicoceles.

## Differential diagnosis

- Hydrocele
- Spermatocele or epididymal cyst
- Inguinal hernia
- Testicular tumour
- Epididymitis

## Goal of treatment

Relieve pain and improve fertility or testicular growth when affected; varicoceles without symptoms or semen changes are observed.

## Treatment

**Follow-up**
Observation for varicoceles with normal semen and normal testicular growth; adolescents are followed with testicular volume measurements.

**Conservative**
Scrotal support and simple analgesics for mild discomfort.

**Surgical**
Varicocelectomy, preferably microsurgical subinguinal (fewer recurrences and hydroceles); laparoscopic or open approaches are also used.

**Procedure**
Percutaneous embolisation or sclerotherapy of the testicular vein by interventional radiology.

## Complications

- Infertility
- Testicular atrophy or slowed growth in adolescents
- After repair: hydrocele, recurrence, rarely [testicular artery](https://durgical.com/en/anatomy/testicular-artery-pelvis/) injury

## Prognosis

Benign. Repairing a clinical varicocele with abnormal semen often improves semen quality, and pain usually improves; the effect on pregnancy rates varies between studies.

## Test yourself

Think of the answer, then tap the question to see it.

## Why is varicocele more common on the left side?

The left testicular vein is longer and drains at a right angle into the left renal vein, with higher pressure; the right drains obliquely into the IVC.

## What is the classic exam finding in varicocele?

A «bag of worms» above the testis, more obvious standing and with Valsalva, that shrinks lying down.

## Which findings suggest a secondary varicocele?

An isolated right-sided varicocele or one that does not collapse lying down; the abdomen is imaged for a mass.

## How does a varicocele impair fertility?

Higher scrotal temperature, hypoxia and oxidative stress impair sperm production.

## What are the usual indications for varicocele repair?

Clinical varicocele with infertility and abnormal semen, testicular growth delay in adolescents, or persistent pain.

[Add to my cards (5)](https://durgical.app/estudiar/?add=/en/conditions/varicocele/)

## Related conditions

- [Hydrocele](https://durgical.com/en/conditions/hydrocele/)
- [Inguinal hernia](https://durgical.com/en/conditions/inguinal-hernia/)
- [Epididymitis](https://durgical.com/en/conditions/epididymitis/)
- [Testicular cancer](https://durgical.com/en/conditions/testicular-cancer/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Varicocele](https://www.ncbi.nlm.nih.gov/books/NBK448113/) (StatPearls (NCBI Bookshelf), 2023).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/conditions/varicocele/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/varicocele/