What is a varicocele?
A varicocele is an enlargement and twisting of the network of veins that carry blood away from the testicle (the pampiniform plexus). It can be compared to varicose veins in the legs. It is a common condition in the general male population, and it is even more common in men who are unable to father children.
The great majority of varicoceles occur on the left side. This is because the left testicular vein drains into the kidney vein at a right angle and over a longer course, which makes it more prone to backflow. Varicoceles can also occur on both sides. For a varicocele that has newly appeared on the right side only, or one that does not disappear when lying down, additional imaging is recommended to look for another underlying cause.
A varicocele usually appears during puberty and, being harmless, may go unnoticed for years.
Symptoms of varicocele
Most varicoceles cause no symptoms and are noticed during a routine examination, an adolescent check-up or an infertility assessment. When symptoms do occur, they may include:
- A dull ache or feeling of heaviness in the testicle, especially after standing for long periods or exercise
- Discomfort that eases when lying down
- A soft swelling in the scrotum that feels like a “bag of worms” to the touch
- In some patients, shrinkage of the testicle on the side of the varicocele
How is it diagnosed?
Physical examination
A varicocele is examined while standing; the patient is asked to bear down (Valsalva manoeuvre) so that the enlargement of the veins can be assessed. Varicoceles are graded according to the examination findings:
- Grade 1: Can be felt only when bearing down.
- Grade 2: Can be felt without bearing down, but is not visible.
- Grade 3: Visible through the skin of the scrotum.
Varicoceles that cannot be felt on examination and are detected only by ultrasound are called subclinical varicoceles.
Colour Doppler ultrasound
Used to support the examination findings, measure the width of the veins and backflow, and assess testicular volumes. It is particularly useful when examination is difficult and for monitoring testicular growth in adolescents. It is a quick examination that involves no radiation. Ultrasound also assesses the testicular tissue itself, checking whether there is any problem in the testicle other than the varicocele.
Semen analysis and additional tests
In adults who wish to have children, sperm count, motility and shape are assessed with a semen analysis (spermiogram). In selected patients, hormone tests and tests showing sperm DNA damage may also be requested.
Varicocele and infertility
A varicocele can have a negative effect on sperm production through increased testicular temperature and changes in blood circulation. Reduced sperm count and motility and increased sperm DNA damage (fragmentation) have been associated with varicocele. Nevertheless, a large proportion of men with a varicocele can father children naturally. This is why the presence of a varicocele alone does not mean infertility; the assessment is carried out for the couple, together with the female partner’s situation. For details, see the male infertility page.
Varicocele in adolescents
During puberty, a varicocele can cause the testicle on the same side to lag behind in growth in some young men. In this age group, testicular volumes are measured at regular intervals. A marked and persistent difference in size of the testicle on the side of the varicocele is an important criterion in the treatment decision.
When is a varicocele treated?
Not every varicocele needs treatment. In line with current guidelines, treatment is generally considered in the following situations:
- In couples unable to conceive where the man has a varicocele that can be felt on examination and abnormal semen parameters (if no significant problem has been found in the female partner)
- When there is pain that affects daily life and does not improve with other methods
- In adolescents whose testicular growth is markedly and persistently lagging behind
Treatment is generally not recommended for adults with no symptoms and normal semen parameters, or for subclinical varicoceles. The decision is made individually after the examination.
Treatment methods
Microsurgical subinguinal varicocelectomy
Access is through a small incision just below the groin, and the enlarged veins are tied off one by one under an operating microscope. Thanks to the microscopic magnification, the artery supplying the testicle and the lymphatic vessels can be preserved. This approach has been associated with a lower risk of recurrence and of fluid build-up after surgery (hydrocele) than other surgical methods, which is why it is the preferred surgical method in suitable patients. The operation is carried out under general or spinal anaesthesia.
Embolisation
Performed by interventional radiology: the enlarged vein is blocked from the inside using a thin catheter passed through a vein in the groin or neck. It is an alternative that requires no incision; however, for anatomical reasons, it may not be possible in every patient.
Laparoscopic and open methods performed above the groin also exist; which method is suitable is decided after the examination.
After surgery and risks
After microsurgical varicocelectomy, patients usually go home the same day or the next day. There may be mild pain and swelling for a few days; supportive underwear and cold packs help. Most people can return to desk work within a few days; it is usual to wait 1–2 weeks before strenuous exercise.
Possible risks include recurrence, fluid build-up around the testicle (hydrocele) and, rarely, injury to the testicular artery. Because the sperm production cycle takes about three months, the effect of surgery is usually assessed with a follow-up semen analysis 3–6 months later.
Can varicocele be prevented?
Varicocele is related to the structure of the veins and to anatomical features; there is no known way to prevent it. It has not been shown that tight underwear causes varicocele or that loose underwear prevents it. However, standing for long periods, heavy lifting and hot environments can increase pain in men with symptoms; supportive underwear may bring relief for them.
To protect sperm quality, men planning to have children are generally advised to stop smoking, maintain a healthy weight and avoid prolonged heat exposure of the testicles.
When should you see a doctor?
A urological examination is recommended if you notice swelling or vein-like structures in the scrotum, have pain or a feeling of heaviness in the testicles, or if your partner has not become pregnant despite a year of regular intercourse. In adolescents, parents noticing a difference in the size of the testicles is also a reason for assessment. Sudden, severe testicular pain, on the other hand, may be a sign of a different condition that requires emergency treatment; in that case, go to the nearest emergency department without delay.
Varicocele treatment in Bursa, Turkey
Op. Dr. Mücahit Kabar graduated from Uludağ University Faculty of Medicine and completed his urology residency at the Urology Clinic of Ankara Training and Research Hospital. He has a scientific study, published in an international peer-reviewed journal, examining the effect of varicocelectomy on sperm DNA damage in infertile patients. He sees patients with varicocele and male infertility in Bursa (Nilüfer) at Özel Medicabil Nilüfer Hastanesi (weekdays 08:30–12:00) and Özel Jimer Hastanesi (weekdays 13:00–17:00).
Consultations are held in English or Turkish. The hospitals’ international patient departments can arrange interpreters for other languages and help with airport transfers and accommodation. If you are travelling from abroad, you can book your appointment in advance through the online booking page or appointment line of Özel Medicabil Nilüfer Hastanesi (weekdays 08:30–12:00, +90 444 8 112) or Özel Jimer Hastanesi (weekdays 13:00–17:00, +90 444 45 67). You can share your semen analysis and ultrasound reports beforehand via WhatsApp (+90 541 622 54 82). More information is available on the international patients page and the contact page.
