Varicocele: Diagnosis, Fertility and Treatment Decisions

A varicocele is an abnormal enlargement of veins in the scrotum, most often on the left side. It may be found during examination, during an infertility work-up or while investigating scrotal discomfort. The important question is not simply whether enlarged veins can be seen on ultrasound, but whether there is a clinical varicocele, symptoms, abnormal semen findings, testicular effects or another reason that makes treatment relevant.

What is a varicocele?

The pampiniform venous plexus drains blood from the testis. When these veins become dilated and reflux is present, the condition is called a varicocele.

Varicoceles are commonly graded clinically:

• Grade 1: palpable during a Valsalva manoeuvre;
• Grade 2: palpable at rest;
• Grade 3: visible and palpable at rest.

A subclinical varicocele is not palpable or visible on physical examination and is detected only with imaging such as Doppler ultrasound.

This distinction matters because guideline-based treatment decisions are not the same for clinical and subclinical disease.

What symptoms can a varicocele cause?

Many varicoceles cause no symptoms. When symptoms occur, they may include:

• a dull or dragging scrotal ache;
• heaviness that becomes more noticeable after prolonged standing or activity;
• visible or palpable enlarged veins;
• testicular asymmetry or reduced testicular volume;
• abnormal semen parameters identified during fertility assessment.

A varicocele is not the only cause of scrotal pain, and acute severe pain should not be attributed to varicocele without assessment.

What does varicocele pain usually feel like?

Pain associated with varicocele is often described as dull, aching or heavy rather than sudden and severe. It may worsen with standing, exertion or later in the day and improve when lying down.

However, symptom pattern alone cannot establish the diagnosis. Epididymal disease, hernia, testicular tumour, infection, torsion and musculoskeletal pain can produce overlapping symptoms.

Sudden severe testicular pain, particularly with swelling, nausea or a high-riding testis, requires urgent assessment because testicular torsion is a time-sensitive emergency.

Does a varicocele cause infertility?

A varicocele can be associated with impaired testicular function and abnormal semen parameters in some men, but it does not mean that every affected man is infertile.

The fertility relevance depends on several factors, including:

• whether the varicocele is clinically palpable;
• semen-analysis findings;
• testicular volume and function;
• other male fertility factors;
• the female partner’s age and ovarian reserve;
• whether another explanation for infertility is present.

For a broader work-up, see male infertility.

Does varicocele cause erectile dysfunction or low testosterone?

Varicocele is primarily a testicular venous condition. It should not be used as a default explanation for erectile dysfunction, reduced libido or every abnormal testosterone result.

Some men with impaired testicular function may also have endocrine abnormalities, but sexual symptoms require their own assessment. Erectile dysfunction can have vascular, metabolic, neurological, medication-related and psychological contributors independent of varicocele.

See erectile dysfunction if erection quality is a separate concern.

How is varicocele diagnosed?

Clinical diagnosis is based mainly on physical examination, usually while standing and with a Valsalva manoeuvre when needed.

Examination can assess:

• whether dilated veins are palpable;
• the side and clinical grade;
• testicular size and consistency;
• other scrotal or groin abnormalities;
• whether the findings fit the reported pain or fertility problem.

A varicocele found only because a scan was performed is not automatically equivalent to a clinically significant varicocele.

What is the difference between clinical and subclinical varicocele?

A clinical varicocele can be detected on physical examination. A subclinical varicocele is detected only by imaging.

This difference changes management. Current EAU guidance recommends against treating subclinical varicocele in infertile men, and also recommends against varicocele treatment when semen analysis is normal solely for an infertility indication.

An ultrasound report therefore should not be read as an automatic indication for surgery.

When is Doppler ultrasound useful?

Scrotal colour Doppler ultrasound is useful when:

• physical examination is inconclusive;
• the anatomy is difficult to assess clinically;
• another scrotal abnormality needs evaluation;
• persistent or recurrent varicocele is suspected after treatment.

The EAU notes that venous diameter and reflux can support the diagnosis, but imaging remains part of the clinical context rather than a stand-alone treatment decision.

An isolated right-sided clinical varicocele deserves additional clinical attention because abdominal, retroperitoneal or congenital causes may need to be considered depending on the presentation.

When is semen analysis useful?

Semen analysis is particularly relevant when fertility is a concern. It assesses the ejaculate using standardized laboratory methods and may identify changes in sperm concentration, total number, motility or morphology.

A single abnormal parameter does not define sterility. If a baseline semen analysis is abnormal, current EAU guidance supports repeat testing before major decisions are made.

Does everyone need hormone or sperm DNA testing?

No. Hormone testing is selected according to the overall infertility picture, testicular findings and semen results.

Sperm DNA fragmentation is also not a routine test for every man with a varicocele. It may be considered in selected infertility situations, including unexplained infertility, recurrent pregnancy loss or assisted-reproduction failure, but the result requires careful interpretation.

Does every varicocele need treatment?

No. Many varicoceles are observed rather than treated.

Treatment becomes more relevant when there is a clinically meaningful problem that the varicocele plausibly contributes to. Examples include selected men with infertility and abnormal semen parameters, persistent characteristic pain, or testicular growth/volume concerns in adolescents.

The decision should reflect the whole reproductive context rather than ultrasound appearance alone.

When may treatment be considered for infertility?

Current EAU guidance supports varicocele repair in infertile men when all of the following are present:

• a clinical varicocele;
• abnormal semen parameters;
• otherwise unexplained male-factor infertility;
• a couple context in which treatment has a realistic reproductive rationale, including consideration of the female partner’s ovarian reserve and time factors.

Varicocele repair may improve pregnancy rates and sperm concentration in appropriately selected men, but improvement in motility and morphology is less certain. No individual can be promised a specific fertility outcome.

When is treatment generally not recommended for fertility?

For infertility alone, treatment is generally not recommended when:

• the varicocele is subclinical and found only on imaging;
• semen analysis is normal;
• another fertility factor makes varicocele repair unlikely to change the reproductive plan.

This is why a scan result should not be separated from semen analysis and couple-based fertility assessment.

How is varicocele treated?

Treatment aims to interrupt abnormal venous reflux while preserving arterial, lymphatic and testicular structures.

Approaches can include:

• microsurgical inguinal or subinguinal varicocelectomy;
• other surgical ligation techniques;
• radiological embolisation in selected settings.

Technique selection depends on anatomy, local expertise, previous procedures and the reason for treatment. Current EAU evidence suggests microscopic inguinal/subinguinal techniques may have lower recurrence and complication rates than some non-microscopic approaches, although procedure choice remains individualized.

What are the risks of treatment?

Potential complications can include:

• recurrence or persistent varicocele;
• hydrocele;
• bleeding or haematoma;
• infection;
• persistent pain;
• injury to nearby structures;
• rarely, compromise of testicular blood supply.

The risk profile varies by technique and patient anatomy. A treatment recommendation should include the expected benefit, alternatives and the possibility that symptoms or semen values may not improve.

Do semen values improve immediately after repair?

No. Spermatogenesis is a biological cycle, so semen changes are assessed over time rather than immediately after treatment. Follow-up timing depends on the fertility plan and treating team.

Even when semen parameters improve, spontaneous pregnancy may still not occur. Conversely, treatment decisions should not be judged from one early semen sample.

Can varicocele recur?

Yes. Persistence or recurrence can occur after any treatment. If symptoms, examination findings or semen abnormalities remain relevant, reassessment may include physical examination and Doppler ultrasound.

Recurrent veins do not automatically mean a second procedure is required; the clinical significance needs to be re-established.

When should evaluation not be delayed?

Seek prompt assessment for:

• sudden severe testicular pain;
• rapidly developing swelling;
• fever with scrotal pain;
• a hard or persistent testicular mass;
• marked change in testicular size;
• a new isolated right-sided varicocele with concerning features;
• pain that does not fit the usual varicocele pattern.

These features may point to diagnoses other than uncomplicated varicocele.

Medical information note

A varicocele is a clinical diagnosis with variable significance. Treatment should not be based on ultrasound wording alone; symptoms, physical examination, semen findings, reproductive goals and alternative explanations all matter.