Varicocele: Symptoms, Types, Causes and Treatment

Varicocele is a common, yet often misunderstood, condition that affects millions of men worldwide. Characterized by the abnormal enlargement of veins within the scrotum, varicocele can have a significant impact on quality of life, fertility, and overall health. In this comprehensive article, we’ll break down everything you need to know about varicocele—including its symptoms, types, causes, and current treatment options—using the latest research and clinical evidence.

Symptoms of Varicocele

Varicocele often goes unnoticed until it impacts comfort or fertility, making symptom recognition essential. While many men may be asymptomatic, others experience a range of symptoms that can affect daily life and reproductive health. Understanding the variations in presentation helps in early detection and management.

Symptom	Description	Frequency/Impact	Source(s)
Scrotal pain	Dull, aching, or throbbing pain	Common, worsens with activity	1, 2
"Bag of worms"	Palpable, enlarged scrotal veins	Classic clinical sign	2
Infertility	Impaired sperm production/quality	Present in many cases	2, 3, 4, 5, 6
Asymptomatic	No noticeable symptoms	Many cases	2
Testicular atrophy	Reduced testicular size	Sometimes observed	8, 9

Table 1: Key Symptoms

Common Symptoms and Clinical Presentation

• Scrotal Pain: One of the most frequently reported symptoms is a chronic, dull, aching pain in the scrotum. The pain is often described as a feeling of heaviness or discomfort that tends to worsen with physical activity or prolonged standing and typically improves when lying down. Some men report throbbing sensations, which have been found to occur more often in those with varicocele than without 1, 2.
• Palpable Veins—“Bag of Worms”: Clinically, varicocele is often identified by a mass of enlarged veins in the scrotum that feels like a "bag of worms." This is a hallmark physical finding during examination 2.
• Infertility: A substantial number of men with varicocele experience infertility. Research shows varicocele is the most common correctable cause of male infertility 2, 3, 4, 5, 6.
• Asymptomatic Cases: Many men have no noticeable symptoms and may only discover the condition during evaluation for infertility or a routine physical exam 2.
• Testicular Atrophy: In some cases, particularly among adolescents, varicocele can lead to a reduction in testicular volume (atrophy) 8, 9.

Impact on Quality of Life

Symptoms such as aching, heaviness, and throbbing can significantly affect daily life and overall well-being. Studies have shown that men with varicocele have lower quality-of-life scores related to venous symptoms compared to those without the condition 1. Even when asymptomatic, the potential for fertility impairment can cause anxiety and stress.

Symptom Variability

The extent and severity of symptoms can vary greatly. Some men may experience only mild discomfort, while others face persistent pain or reproductive challenges. Importantly, the grade (severity) of varicocele often correlates inversely with symptom scores—the higher the grade, the more symptoms tend to be present 1.

Types of Varicocele

Varicoceles are not all the same. They can be classified by their anatomical characteristics, severity, and clinical detectability. Understanding these distinctions is crucial for diagnosis and treatment planning.

Type	Description	Clinical Importance	Source(s)
Left-sided	Most common; affects left testicular veins	85-90% of cases	5
Right-sided	Less common; may indicate other pathology	Requires thorough evaluation	5
Bilateral	Both sides affected	Seen in some cases	5
Clinical	Detectable by physical exam	Used for treatment decisions	7, 8, 9
Subclinical	Not palpable, diagnosed via imaging	Often not treated	7
Grading (I-III)	I: Small, II: Moderate, III: Large	Guides management	1, 5

Table 2: Types of Varicocele

Anatomical Distribution

• Left-sided Varicocele: The vast majority of varicoceles occur on the left side, owing to anatomical differences in venous drainage. The left testicular vein drains into the left renal vein at a right angle, predisposing it to higher venous pressure and dilation 5.
• Right-sided and Bilateral Varicocele: Right-sided varicocele is uncommon and may necessitate further investigation for secondary causes. Bilateral varicocele, affecting both sides, is less common but still clinically significant 5.

Clinical vs. Subclinical Varicocele

• Clinical Varicocele: These are palpable during a physical examination and are categorized according to their size and prominence. Clinical varicoceles are the primary focus for treatment, especially when associated with symptoms or infertility 7, 8, 9.
• Subclinical Varicocele: These are not detectable by physical exam and are identified only through imaging techniques such as Doppler ultrasound. Subclinical varicoceles are rarely treated unless they are associated with abnormal semen parameters 7.

Grading System

Varicoceles are also graded based on their severity:

• Grade I: Small, palpable only with Valsalva maneuver.
• Grade II: Moderate, palpable without Valsalva.
• Grade III: Large, visible through scrotal skin and easily palpable 1, 5.

These grades help guide treatment decisions and predict impact on fertility and symptoms.

Causes of Varicocele

The development of varicocele is rooted in a complex interplay of anatomical, physiological, and possibly genetic factors. Understanding the underlying causes can help demystify why some men develop the condition and others do not.

Cause	Mechanism/Detail	Key Insights	Source(s)
Venous valve failure	Incompetent or absent valves in testicular veins	Primary cause of reflux	5
Anatomy	Left vein drains into renal vein at right angle	Explains left-side dominance	5
Increased venous pressure	Stasis and dilation of pampiniform plexus	Leads to varicocele formation	3, 5
Oxidative stress	Excess ROS, impaired antioxidant defenses	Contributes to infertility	3, 4, 5
Genetic factors	Gene polymorphisms, protein expression changes	Influence susceptibility	3, 5
Secondary causes	Abdominal masses/tumors compressing veins	Especially in right-side	5

Table 3: Causes of Varicocele

Anatomical and Physiological Mechanisms

• Valve Dysfunction: The most widely accepted cause of varicocele is failure of the one-way valves in the testicular veins. When these valves don’t function properly, blood pools and the veins become enlarged 5.
• Venous Anatomy: The left testicular vein’s unique drainage pattern into the left renal vein at a right angle creates higher pressure compared to the right, explaining why most varicoceles occur on the left 5.
• Venous Pressure and Stasis: Elevated pressure leads to dilation of the pampiniform plexus (the network of veins in the scrotum), resulting in varicocele formation 3, 5.

Molecular and Genetic Factors

• Oxidative Stress: Varicoceles are associated with increased production of reactive oxygen species (ROS), which can damage sperm DNA and the cells responsible for spermatogenesis. Oxidative stress is now recognized as a key mechanism linking varicocele to infertility 3, 4, 5.
• Genetic Susceptibility: Differences in the expression of genes and proteins related to oxidative stress, apoptosis, and heat-shock response may predispose some individuals to develop varicocele or suffer more severe consequences 3, 5.

Secondary (Non-Primary) Causes

While most varicoceles are primary (due to the above mechanisms), secondary varicoceles can result from external compression of the testicular vein, such as by an abdominal mass or tumor. This is more often seen with right-sided varicocele or when onset is sudden and occurs in older men, warranting further evaluation 5.

Treatment of Varicocele

Managing varicocele involves a nuanced approach that balances symptom relief, fertility preservation, and minimizing risks. Treatment options range from conservative observation to surgical and radiological interventions. The choice depends on factors such as symptoms, age, fertility goals, and varicocele severity.

Treatment Option	Approach/Technique	Outcomes & Considerations	Source(s)
Observation	No active intervention	For asymptomatic/subclinical	8, 9, 10
Surgery	Open/laparoscopic/microsurgical	Improves sperm count, less pain	6, 7, 9, 10
Radiological	Embolization/coiling of veins	Minimally invasive, effective	8, 9, 10
Microsurgical repair	Subinguinal microsurgical approach	Lower recurrence/complications	6, 7
Novel therapies	Targeting oxidative stress, genetics	Under investigation	3, 5

Table 4: Treatment Options

Indications for Treatment

• Symptomatic Varicocele: Men experiencing pain, discomfort, or testicular atrophy are often considered for intervention.
• Infertility: Treatment is recommended for men with clinical varicocele, abnormal semen analysis, and infertility 6, 7, 10.
• Adolescents: Decisions are individualized, focusing on testicular growth and future fertility potential 8, 9.

Conservative Management

• Observation: Many men with asymptomatic or subclinical varicocele do not require treatment. Regular follow-up is advised to monitor for symptom development or impact on testicular growth, especially in adolescents 8, 9, 10.

Surgical and Radiological Interventions

• Surgical Varicocelectomy: Techniques include open, laparoscopic, and microsurgical repair. Microsurgical subinguinal varicocelectomy is currently favored due to lower recurrence rates and fewer complications 6, 7.
  • Outcomes: Surgery has been shown to significantly improve sperm concentration, total motility, and progressive motility. There is also evidence for improved pregnancy rates in men with infertility and clinical varicocele 6, 7, 10.
  • Adolescents: Surgery or radiological intervention can improve testicular volume and sperm count, though long-term fertility outcomes remain uncertain 8, 9.
• Radiological Embolization: This minimally invasive procedure involves blocking the affected veins through interventional radiology, providing similar outcomes to surgery in many cases 8, 9, 10.

Addressing Complications and Recurrence

• Postoperative Issues: Persistent or recurrent pain after varicocelectomy may result from recurrence, hydrocele formation, or nerve injury. Careful surgical technique and patient selection are critical to minimize these risks 2, 6.
• Lymphatic Sparing Techniques: These approaches reduce the risk of hydrocele (fluid accumulation around the testicle) after surgery 9.

Novel and Future Therapies

• Targeting Molecular Pathways: Ongoing research focuses on therapies that address oxidative stress, inflammation, and genetic factors. These may offer future non-surgical options for men with varicocele 3, 5.

Limitations of Treatment

Although varicocele repair improves sperm parameters and pregnancy rates in selected men, not all individuals benefit equally. Some studies report no clear advantage in spontaneous pregnancy rates, and the long-term effects on fertility—especially in adolescents—remain under investigation 8, 9, 10.

Conclusion

Varicocele is a multifaceted condition that can impact men’s reproductive and general health in diverse ways. Recognizing its symptoms, understanding the types and underlying causes, and being aware of current treatment options are key steps towards effective management.

Key takeaways:

• Varicocele may present with scrotal pain, a “bag of worms” sensation, infertility, or be asymptomatic.
• Most varicoceles are left-sided and can be classified by severity and clinical detectability.
• The main causes are incompetent venous valves and anatomical factors, with oxidative stress and genetics playing significant roles in some cases.
• Treatment ranges from observation to surgical or radiological intervention, with microsurgical repair offering the best outcomes in many cases.
• Most men see improvements in sperm count and testicular health after treatment, but not all achieve improved fertility.
• Future therapies may target underlying molecular pathways for more personalized care.

Understanding varicocele empowers men to seek timely evaluation and make informed choices about their health and fertility.