Varicocele: what it is, symptoms, diagnosis and treatment

A varicocele is a dilatation of the veins of the testis, with reflux of blood within them. For anatomical reasons it affects the left testis in 90% of cases. It is very common — occurring in about 15% of boys between 15 and 25 years of age — and typically arises at puberty. It is the leading cause of male infertility, and one of the few that is surgically correctable.

Why it forms, and why almost always on the left

Underlying a varicocele is a combination of anatomical, constitutional and hereditary factors that favour dilatation of the veins and stasis of blood at the level of the testis. The marked predominance on the left (about 90% of cases) is due to anatomical reasons, related to the different course of the spermatic vein on the two sides.

Symptoms: often none

A varicocele is frequently asymptomatic, which is one reason it may go unnoticed until an andrological check-up or a fertility problem. When it does cause symptoms, these take the form of aching or a sensation of heaviness in the testis, which tends to worsen in certain circumstances:

• In high temperatures
• After physical exercise
• After sexual intercourse
• After standing or sitting for too long

The grades of varicocele

It is important to establish the grade of the varicocele — I, II or III — because the higher the grade, the greater the potential negative impact on fertility. Grading is one of the elements that guide the decision on whether and when to intervene.

Diagnosis

• Testicular colour Doppler ultrasound: the key investigation, entirely non-invasive, which demonstrates the pathological reflux of blood in the veins of the testis and allows the grade of the varicocele to be established
• Semen analysis (spermiogram): advisable in the adult patient to assess fertility and any impact of the varicocele on the seminal parameters

Treatment

Correction of a varicocele is essentially procedural, with two options.

Surgical correction

Given the extreme delicacy of the structures involved, the operation is performed with the aid of magnification — loupes and/or an operating microscope. It is carried out as day surgery: the patient is operated on and can return home within a few hours. Through a small skin incision (3–4 cm) at the groin, the dilated veins of the testis are reached and ligated.

Percutaneous sclero-embolisation

This is an interventional radiology technique, performed without any skin incision: sclerosing agents are injected into the dilated veins of the testis to close them. The advantage is the absence of an incision; the disadvantage is a higher number of recurrences compared with surgery.

Frequently asked questions about varicocele

Does a varicocele cause infertility?

A varicocele is the leading cause of male infertility. Not every man with a varicocele is infertile, but the venous dilatation and blood stasis can impair the production and quality of sperm, more so the higher the grade. This is why, in the adult, a semen analysis accompanies the assessment of the varicocele.

Does a varicocele always need surgery?

No. The decision depends on the grade, the presence of symptoms, the age, and above all the impact on fertility documented by the semen analysis. In many asymptomatic cases without seminal abnormalities, observation can be chosen. Andrological assessment establishes the indication.

Why does a varicocele almost always occur on the left?

For anatomical reasons related to the different course of the spermatic vein on the two sides: on the left the venous drainage is less favourable, which is why about 90% of varicoceles affect the left testis.

Can a varicocele be corrected without surgery?

Yes, with percutaneous sclero-embolisation, an interventional radiology technique that closes the dilated veins without a skin incision. It carries, however, a higher number of recurrences than surgery. The choice between the two options is made with the specialist according to the individual case.

At what age does a varicocele appear?

Typically at puberty: it occurs in about 15% of boys between 15 and 25 years of age. This is one reason a first andrological examination in adolescence matters: detecting a varicocele early allows its impact on future fertility to be assessed before it becomes a problem.

What is the difference between a varicocele and a hydrocele?

They are two different conditions. A varicocele is a dilatation of the veins of the testis and affects fertility. A hydrocele is a collection of fluid around the testis and does not in itself impair sperm production. Both cause scrotal changes, but with different causes and consequences.

Do you have a varicocele, or would you like your fertility assessed? Ask Prof. Natali for a consultation or book an appointment at his practices in Florence and Empoli, Italy.

The information on this page is provided for general educational purposes and does not replace a medical examination, which remains the only diagnostic tool for correct and effective treatment.