Varicocele: Symptoms, Causes, and Treatments

Varicocele tends to be asymptomatic, but its early diagnosis and timely treatment prevent the most feared complication: infertility. We explain it to you.

Written and verified by the doctor Mariel Mendoza.

Last update: 26 September, 2022

The term varicocele refers to the dilatation of the veins of the scrotum (the skin supporting the testicles). These veins, which belong to the pampiniform plexus, carry deoxygenated blood from the testicles to the heart.

Venous deficiency causes the disorder because the blood pools or backs up instead of circulating out of the area. It’s the equivalent of varicose veins of the lower limbs.

Varicocele is usually unilateral, with up to 90% of cases on the left side of the body. However, it can also be bilateral. This condition is more frequent in young men between 15 and 25 years old, and it has a high prevalence, with 15 cases per 100 males.

Symptoms of varicocele

In general, varicocele is usually asymptomatic, and the finding is often incidental during a routine physical examination. When it does cause problems, it manifests with dull pain, decreased testicular volume, the presence of a lump, or a feeling of heaviness at the scrotal level.

How does it cause fertility problems?

Varicocele causes infertility in about 4 to 8 out of 10 men who have this condition. This is because the pampiniform plexus is responsible for maintaining adequate testicular temperature for the production and maturation of sperm.

The testicles require a lower basal temperature than the rest of the body for their functions. That’s why they’re isolated in their scrotal sac.

The pampiniform plexus is responsible for cooling the blood in the testicular artery before it enters the testicles. Its dilatation causes overheating of the testicles, with the consequent lower production and maturation of spermatozoa. Thus, a man’s fertility potential is affected.

This testicular alteration has other consequences

In addition, by the same alteration of testicular function, there’s a decrease in testosterone production. Even if the varicocele is unilateral, the increase in temperature affects both sides.

The decrease in testosterone production inhibits testicular development while going through puberty. In addition to that, it produces the consequent loss of tissue, which can end in testicular atrophy.

The causes of varicocele

There’s no definitive and single cause of varicocele. Rather, it’s considered a multifactorial condition. Theories are oriented to the absence or deficiency of venous valves, which would allow venous reflux that could form varicose veins.

Similarly, the left predominance is associated with the fact that the testicular vein on that side is longer. Therefore, it has higher hydrostatic pressure. Likewise, the left testicular vein flows into the renal vein at a right angle, which hinders adequate venous return.

It can also be caused by increased blood viscosity, which hinders venous reflux. Or it may be caused by the presence of masses or lymph nodes blocking blood flow.

Varicocele most often occurs during puberty. The testicles present an accelerated growth at that time, so they require more blood flow.

The diagnosis is clinical but can be confirmed with imaging

To diagnose varicocele, a physical examination is sufficient. At the time of scrotal palpation, there’s usually a sensation of a “bag of worms.”

The person should be assessed in both a bipedal (standing) and supine (lying) position. However, varicocele may not be identifiable by physical examination when it’s subclinical. In this case, an ultrasound is helpful.

Sometimes this condition is palpable but not visible. It may also be palpable with or without maneuvers to increase intra-abdominal pressure. That is, it may be detected by asking the patient to perform the Valsalva maneuver.

If varicocele is suspected and there’s no clinical evidence after bilateral manual exploration in the supine decubitus, a standing position, or with increased intra-abdominal pressure, imaging studies are required. These studies should show evidence of blood reflux. A testicular Doppler ultrasonography and venography are the most indicated exams.

Should varicoceles always be treated?

In general, varicoceles aren’t usually treated unless they generate pain or abnormal growth of the left testicle, there’s an abnormal semen analysis or fertility problems. Analgesics may be indicated for pain, but surgery is the main approach for those that do require it.

Surgery can be open or laparoscopic. Embolization may also be performed. An attempt is always made to block blood flow in the pampiniform venous plexus.

Complications are rare and include the following circumstances:

• Persistent or recurrent varicocele
• Hydrocele (fluid around the testicle)
• Inflammation of the epididymis (epididymitis)
• Damage to the testicular artery

Recovery is rapid after surgery since the procedure is outpatient. Rest should only be maintained for 10 to 14 days. A semen analysis should wait 3 to 4 months to confirm improvement if infertility was present.

The procedure is successful in most cases, with evidence of improvement in semen quality. However, a semen analysis should be performed every three months for one year after the procedure.

Varicocele can be reversible

Early diagnosis, especially during puberty, can help prevent serious sequelae, such as testicular atrophy and infertility, especially in the case of symptomatology. For this reason, every man suspected of having a varicocele should undergo a study of their sperm, hormonal values, and testicular volume.

The presence of any major alteration is a criterion for indicating definitive surgical resolution. Currently, the techniques used have few side effects and a high success rate.