Big Ball Series: What You Need to Know About Varicoceles

Andrew Siegel MD  11/17/2018

This is a continuation of the “Big Ball” series of entries, which provide information about common maladies that affect the contents of the scrotum.  The last few entries have covered hydrocele, spermatocele and epididymitis.  The final entry in the series will be next week, which will cover testes tumors–relatively rare occurrences, but one of the most common cancers involving young men. 

VaricoceleBy BruceBlaus [CC BY-SA 4.0  (, from Wikimedia Commons

A varicocele is a clump of varicose veins of the spermatic cord, the bundle of tissue containing the testicle’s blood supply. A varicocele causes an engorgement of blood that heats up the testicles, which is undesirable for optimal sperm production and fertility.  The reason testes are external to the core of the body is their necessity for temperatures lower than core temperatures; if testicular temperature is too high, sperm development can be negatively affected.

Varicoceles are not uncommon, found in about 20% of adult males.  Varicoceles are found commonly in infertile men, including 40% of men with primary infertility (unable to achieve pregnancy after at least 12 months of unprotected sexual intercourse) and 80% of men with secondary infertility (previously able to achieve pregnancy, but currently unable to do so).

Normally functioning veins have small valves that allow for only one direction of venous flow (backwards towards the heart).  A varicose vein has faulty valves that allow reverse direction of blood flow with gravitational maneuvers such as standing and straining. This causes a fullness in the cord of tissue in the scrotum immediately above the testes (spermatic cord).  Although many varicoceles do not cause symptoms, others give rise to fertility issues or a dull achy pain when the varicose veins are full.  90% of varicoceles are on the left side because of differences in venous drainage patterns of the left and right testicular veins.


Although men who have large varicoceles often complain of a mass or bulkiness felt immediately above the testes, many are diagnosed on physical examination in men who have no symptoms. They classically feel like a “bag of worms,” are most common on the left side and often cause the testes to be lower and lie horizontally as opposed to its normal vertical axis. They become more pronounced with straining and heavy lifting. They can vary from small, asymptomatic, unnoticeable varicosities that are only detected by your physician, to very large, symptomatic varicosities that can cause shrinkage of the involved testes, testicular pain and fertility issues.

Grading of varicoceles

Grade I: felt only upon asking patient to strain

Grade II: felt when patient stands

Grade III: visible

Ultrasound is a simple and non-invasive means of imaging the varicocele and the testes and is capable of diagnosing a small varicocele that is not evident on physical exam.

Varicoceles and fertility

It is important to know that most men with varicoceles are not infertile, but varicoceles are found commonly in infertile men. Varicoceles are associated with impaired sperm production and sub-fertility and are the most common correctable cause of male infertility. Varicoceles can negatively affect sperm count, motility and appearance.  In general, the higher the grade of varicocele, the greater the negative effect on fertility.  Proposed mechanisms for the impaired fertility are downward reflux of kidney and adrenal gland toxins, decreased testicular oxygen levels, increased testicular temperature that can affect sperm development, abnormal testicular blood flow, hormone imbalances, increased sperm DNA fragmentation, and oxidative stress.

Varicoceles merit treatment if there is discomfort or pain associated with gravitational and strain maneuvers or in the face of infertility. In the adolescent population, pediatric urologists generally repair varicoceles when there is discrepancy in the size of the testicles and when the smaller testicle is noted on the side of the varicocele.  In this setting, the goal of surgery is to improve testicular volume and sperm concentration.


An asymptomatic varicocele causing no pain or fertility issues needs no treatment. Treatment is recommended for men with infertility or chronic discomfort associated with the varicocele. The goal of treatment is to occlude all of the varicose veins draining the affected testes, to improve the fertility issue and/or the pain issue.  This can be achieved with surgery or embolization.  Surgery can be on an outpatient basis done laparoscopically or open, with the laparoscopic approach often chosen in children because of smaller caliber veins present in children.  Open surgery is done via a small groin incision with magnification. Each varicose vein is identified and tied off with suture to prevent the back flow of blood.  Potential side effects of surgery include testes arterial injury, hydrocele, testes atrophy and recurrent varicocele.

Percutaneous embolization is a non-surgical alternative done by interventional radiology. Using fluoroscopic guidance, the varicose veins are identified and occluded with permanent coils that are placed percutaneously.  Potential side effects include blood vessel perforation and coil migration.


Men can expect an average increase in sperm count of 10 million/cc, a 10% increase in motility and increased overall pregnancy rates.  Serum testosterone levels often increase as well.  About 70% of men will experience an improved semen analyses following varicocele repair with resulting conception in about 50%.

What you can do to keep your testes cool and functional

 Careful with the following habits:

  • Hot baths, saunas, steam rooms
  • Heated car seats
  • Keeping your laptop on your lap
  • Cycling in tight shorts
  • Wearing tight underwear


Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food


These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

New video on female pelvic floor exercises:  Learn about your pelvic floor


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