What are varicoceles?

A varicocele is a condition that occurs when a cluster of veins that become dilated inside a man's scrotum. These veins, called the pampiniform plexus are responsible for draining the blood from the testis and regulating their temperature. They start at the back of the testis and run along the spermatic cord at the front of the ductus deferens (the duct that helps transport sperm). This condition is similar to vericose veins that you might find in your leg. However, in the case of varicoceles, the skin of the scrotum is often too think to see the underlying condition.

Varicoceles most often form during puberty but often grow larger, more symptomatic, or noticeable as the person ages. Typically varicoceles manifest on the left side of the scrotum. About 10 to 15 men of 100 have a varicocele. For most of these men, varicoceles are asymptomatic and are harmless. However, more severe cases of vericocele can result in infertility due to decreased sperm production and quality. Varicoceles can also cause testicles in boys experiencing puberty to under-develop or shrink.

What causes varicoceles?

While sometimes incorrectly attributed to exercise or heavy lifting, the direct causes of varicoceles are not fully understood.

Sometimes varicoceles can be attributed the valves in the veins that go along the spermatic cord not working correctly. This leads to a backflow flow of blood to the testicles.

What are the symptoms of a varicocele?

Most men will not experience varicocele symptoms. Some men, however, may feel a dull discomfort in the affected testicle, especially after exercising, standing for a long time, or at the end of the day. The discomfort will usually improve when the man lies down. Additionally, infertility is often a major symptom that alerts doctors to check for and diagnose a varicocele. 

In most cases, the skin of the scrotum is too think to only visually diagnose a varicocele. However, if the varicocele is large enough, it may present as a tortuous mass (sometimes described as feeling like a "bag of worms" in the scrotum).

The testicle on the same side as the varicocele may be smaller than expected. If the varicocele is treated and repaired in childhood or adolescence, the testicle may grow to “catch up” in size. Testicle size does not increase when the varicocele is repaired in adults.

How is a varicocele diagnosed?

Cleveland Clinic physicians can diagnose a varicocele during a physical examination by palpating, or feeling, the spermatic cord while the patient is standing. A varicocele is described as feeling like a "bag of worms" in the scrotal sac. Additionally, the testicle with the varicocele may be smaller than the other testicle.

Physicians typically prefer the patient to stand during the test because the veins may become deflated (and thus harder to detect) when laying down.

In some cases, the doctor may perform a scrotal ultrasound to confirm the diagnosis of varicoceles. Ultrasound, also known as sonography, or ultrasonography, is a procedure that transmits high-frequency sound waves through body tissues. The echoes are recorded and transformed into video or photographs of the inside of the body. This test helps doctors to understand the severity of the varicocele.

Semen tests and blood tests may be recommended in men with a varicocele who are concerned about their fertility. Depending on the size and severity of the varicocele will determine what steps you can take with your physician to proceed with treatment.

How are varicoceles treated?

While not every varicocele needs to be corrected, there are situations where treating a varicocele can significantly improve fertility. Further, there are steps a man can take to avoid varicocele discomfort:

  • Wearing a jockstrap during strenuous activities or prolonged standing;
  • Avoiding activity that causes the discomfort;
  • Taking the occasional over-the-counter pain reliever such as ibuprofen or acetaminophen as advised by your doctor.

If these non-invasive treatments are not effective enough, or a man is concerned about his fertility, he can choose to pursue surgical intervention.

The relationship between having a varicocele and having reduced semen quality is strong, but it is not 100 percent. Each couple must be evaluated for their unique infertility factors. Just because a man has a varicocele does not mean he will have trouble fathering a child. Even if a man has a varicocele and also abnormal semen quality, the varicocele may not always account for the fertility problem. Suspicion should be high that the varicocele is part of the problem, however. Overall, research suggests that about two-thirds of men who have procedures to fix a varicocele improve at least one aspect of their semen quality. About 40 percent ultimately establish a pregnancy.

Surgical Treatment of a Varicocele

The most common way of correcting a varicocele is to use surgery to tie off the dilated veins. The veins are easiest to spot in the scrotum, but the incision is made in the groin area or upper scrotum where many veins join to become few. Those remaining veins are tied off with delicate sutures. In recent years, urologists who are experienced microsurgeons have used the operating microscope to magnify even the smallest veins. This may allow them to effectively tie off all the dilated veins through a smaller incision. Other surgeons still prefer the more standard approach, using a somewhat larger incision in the groin area, similar to one that would be made to repair a hernia.

In laparoscopy (also known as minimally invasive surgery), a thin telescope is inserted into the body through a small opening just below the navel. This type of approach can be used to tie off the varicocele at the point where the veins enter the muscular opening in the wall of the abdomen. After the patient is given general anesthesia, a thin telescope attached to a camera is inserted through the small incision, followed by two smaller probes that are passed through tiny openings made on each side between the navel and the pubic bone. These probes form a passageway through which surgical instruments can be passed. The surgeon uses these instruments to separate the veins of the varicocele from the artery and lymph vessels. Then the surgeon passes a special stapling tool through one of the small openings and blocks off the veins using stainless steel clips.

Transvenous Treatment of a Varicocele

There is even a way of correcting a varicocele without making a surgical incision at all. This method is called transvenous (i.e., through the vein) embolization (i.e., creation of a clot in a vein). Embolization is done by an interventional radiologist who has had special training. The radiologist uses an X-ray viewing screen (fluoroscope) to see the blood vessels in the crucial area. A very thin tube, called a catheter, is threaded into a neck vein (jugular vein) or thigh vein (femoral vein). Under X-ray guidance, it is passed through the larger blood vessels until it reaches the veins that drain the testicle. This catheter is about the size of a thin spaghetti noodle. The vein and its branches are identified by injecting them with a special X-ray contrast material (dye).

Now that the target can be seen, the radiologist plugs the varicocele by passing small stainless steel coils through the catheter and releasing them into each branch of the varicocele. The coils stay in place, creating a blood clot that effectively blocks the vein. In addition to the small coils, an irritating liquid (such as a dense sugar solution) can be injected through the catheter. When the liquid hits the vein, it causes a scarring process to begin, which ultimately shuts off blood flow through the vein. Embolization can be done with very little recovery time. Men are often back to full activities within two days-shorter even than the healing time after microscopic or laparoscopic surgery.