Varicocele

A varicocele is an abnormal dilation of the pampiniform venous plexus within the spermatic cord, found in approximately 15% of all men, with prevalence increasing to 35% in men with primary infertility and up to 80% in men with secondary infertility.[1-2] Most varicoceles are left-sided (85–90%) due to the anatomy of the left testicular venous drainage into the left renal vein.[1][3] The following is a clinically organized summary for emergency medicine and primary care evaluation.

1. History

• Onset, duration, and character of scrotal symptoms (most are asymptomatic and found incidentally)[1]
• Dull ache or scrotal heaviness, often worse with prolonged standing or exertion, improved with recumbency[1][4]
• Fertility history: duration of attempting conception, prior pregnancies, partner's fertility status[5]
• Sexual history and prior STI screening (to differentiate from epididymitis)
• History of trauma to the scrotum
• Timing relative to puberty in adolescents (varicoceles become more common as puberty begins)[6]
• Ask about rapid onset of new right-sided or bilateral scrotal swelling (may suggest secondary cause)[1]

2. Alarm Features

• Isolated right-sided varicocele → must evaluate for retroperitoneal mass (e.g., renal cell carcinoma) compressing the IVC or right gonadal vein[1]
• New-onset varicocele in an older man (>40 years) → consider retroperitoneal or pelvic malignancy causing venous obstruction
• Varicocele that does not decompress in the supine position → suggests venous obstruction from a mass[5]
• Acute severe scrotal pain → rule out testicular torsion (surgical emergency, salvage rate ~90% within 6 hours)[1]
• Hard, non-tender testicular mass → concern for testicular cancer[1]
• Constitutional symptoms (weight loss, fever, night sweats) → malignancy workup

3. Medications

• No specific medications cause varicoceles
• Symptomatic management of pain: NSAIDs (ibuprofen 400–600 mg PO q6–8h) and scrotal support
• Acetaminophen as an alternative analgesic
• No role for empiric antibiotics unless epididymitis is suspected
• In the fertility context, antioxidant supplements (e.g., vitamin C, vitamin E, CoQ10) have been studied but lack definitive evidence for routine use

4. Diet

• No specific dietary triggers or restrictions for varicocele
• General recommendations for men with fertility concerns: balanced diet rich in antioxidants, adequate hydration
• Avoidance of excessive heat exposure to the scrotum (hot tubs, saunas, laptops on lap) may be relevant in the fertility context given the role of scrotal hyperthermia in varicocele pathophysiology[2]

5. Review of Systems

• GU: dysuria, hematuria, urethral discharge, testicular pain, erectile dysfunction
• Constitutional: fever, weight loss, fatigue (malignancy red flags)
• GI/Abdominal: flank pain, abdominal mass (retroperitoneal pathology)
• Musculoskeletal: groin or inguinal pain (hernia vs. referred pain)
• Reproductive: libido changes, prior semen analyses, hypogonadal symptoms (fatigue, decreased energy — larger varicoceles may impact testosterone production)[2][5]

6. Collateral History and Family History

• Family history of infertility or varicocele
• Family history of renal cell carcinoma or retroperitoneal malignancy (relevant if isolated right-sided or new-onset varicocele)
• Partner's reproductive history and gynecologic evaluation status
• Social context: occupations requiring prolonged standing may exacerbate symptoms

7. Risk Factors

• Age: typically presents during puberty (peak onset 15–25 years)[6-7]
• Tall stature (longer gonadal vein)
• Left-sided predominance due to the left gonadal vein draining into the left renal vein at a right angle[1][3]
• Incompetent or absent venous valves in the internal spermatic vein
• Possible genetic predisposition[8]
• No clear modifiable lifestyle risk factors

8. Differential Diagnosis

• The following algorithm from the AAFP provides a systematic approach to evaluating scrotal masses:
• Hydrocele: painless, smooth, fluctuant, transilluminates; extratesticular[1]
• Spermatocele/epididymal cyst: painless cystic mass at the head of the epididymis; transilluminates
• Inguinal hernia: reducible mass, palpable impulse with Valsalva, extends into inguinal canal[4]
• Epididymitis: painful, gradual onset, tenderness over epididymis, positive Prehn sign, often infectious[1]
• Testicular torsion: acute severe pain, high-riding testis, absent cremasteric reflex — surgical emergency[1]
• Testicular cancer: firm, non-tender, unilateral intratesticular mass; does not transilluminate[1]
• Torsion of testicular appendage: gradual onset of superior pole pain, "blue dot" sign[1]

9. Past Medical History

• Prior scrotal surgery or varicocele repair (recurrence rate varies by technique)
• History of cryptorchidism (associated with both infertility and testicular cancer risk)
• Prior fertility evaluations or semen analyses
• Chronic conditions: renal disease, retroperitoneal surgery, or known malignancy
• History of DVT or venous insufficiency

10. Physical Exam

• Examine patient standing in a warm room; inspect and palpate both hemiscrotums[3][5]
• Classic finding: "bag of worms" palpable above and posterior to the testis[1][5]
• Perform Valsalva maneuver — varicocele should increase in size with Valsalva and decompress when supine[3][5]

Grading (WHO)

• Grade I: palpable only with Valsalva
• Grade II: palpable at rest in upright position
• Grade III: visible at rest in upright position
• Assess testicular size bilaterally — ipsilateral testicular atrophy suggests varicocele-related damage[5]
• Check cremasteric reflex (to rule out torsion)[1]
• Palpate inguinal canals for hernia
• Transilluminate to differentiate from hydrocele[1]
• Abdominal exam if concern for retroperitoneal mass

11. Lab Studies

• Routine labs are generally not needed for uncomplicated varicocele[1]

If fertility concern

• Semen analysis (at least two) — assess count, motility, morphology[5]
• FSH, LH, testosterone — to evaluate for hypogonadism; elevated FSH may indicate impaired spermatogenesis[5]
• Inhibin B — marker of Sertoli cell function (research setting)
• If testicular mass suspected: AFP, β-hCG, LDH (tumor markers)[1]
• If epididymitis suspected: urinalysis, urine culture, GC/chlamydia NAAT
• Sperm DNA fragmentation testing is emerging but not yet routine[8]

12. Imaging

• Scrotal ultrasound with color Doppler is the first-line imaging modality when physical exam is inconclusive[5][9-10]
• Diagnostic criteria: spermatic veins >2.5–3.0 mm in diameter with retrograde flow on Valsalva[5]
• Also assesses testicular volume discrepancy
• Imaging is not indicated for routine screening if the varicocele is clearly palpable[5][11]
• CT abdomen/pelvis: indicated for isolated right-sided varicocele or new-onset varicocele in older men to rule out retroperitoneal mass[1]
• Spermatic venography: reserved for recurrent or persistent varicocele post-repair[5]
• Shear wave elastography is an emerging modality under investigation[8]

13. Special Tests

• TWIST score (Testicular Workup for Ischemia and Suspected Torsion): useful when acute scrotal pain is the presenting complaint to risk-stratify for torsion[1]
• Orchidometer or ultrasound volumetry for serial testicular volume measurement in adolescents[12]
• Peak retrograde flow (PRF) on Doppler: PRF >38 cm/s may indicate higher risk of testicular dysfunction in adolescents[6]

14. ECG

• Not applicable for varicocele evaluation

15. Assessment

• Varicocele is a common, usually benign condition that is most often asymptomatic and discovered incidentally or during infertility evaluation.[1] Key clinical considerations:
• Only clinically palpable varicoceles have been clearly associated with infertility[5][11]
• Subclinical varicoceles (detected only by imaging) have no demonstrated benefit from treatment[5][11]
• The mechanism of fertility impairment is multifactorial: scrotal hyperthermia, oxidative stress, testicular hypoxia, and blood-testis barrier disruption[2]
• Larger varicoceles may have a greater impact on semen parameters and testosterone production[2][5]
• Severity stratification should incorporate varicocele grade, testicular volume asymmetry, semen parameters, and hormonal profile

16. Treatment Plan

Conservative management (majority of patients)

• Scrotal support (supportive underwear)
• NSAIDs for symptomatic pain
• Observation with serial semen analyses every 1–2 years for young men with normal semen parameters[5]
• Indications for varicocele repair (per AUA/ASRM guidelines):[5][11]
• Palpable varicocele + known infertility + abnormal semen parameters + female partner with normal or treatable fertility
• Palpable varicocele + pain refractory to conservative measures
• Adolescents with ipsilateral testicular volume loss (≥20% asymmetry) or abnormal semen analysis[5-6]

Surgical options

• Microsurgical subinguinal varicocelectomy — gold standard; lowest recurrence (~1%) and complication rates[5][8]
• Inguinal microsurgical approach — similar outcomes
• Laparoscopic varicocelectomy — higher recurrence than microsurgical
• Percutaneous embolization — minimally invasive alternative; comparable efficacy[5]

Repair is NOT indicated for

• Subclinical (non-palpable) varicoceles
• Normal semen quality
• Isolated teratozoospermia
• Time to improvement in semen parameters post-repair: approximately 3–6 months.[5]

17. Disposition

• Outpatient management is appropriate for the vast majority of varicoceles[13]

Urology referral indications

• Infertility with palpable varicocele and abnormal semen parameters[5][11]
• Symptomatic varicocele refractory to conservative measures
• Adolescent with testicular volume asymmetry or abnormal semen analysis[5][12]
• Isolated right-sided varicocele (after retroperitoneal imaging)[1]
• Suspicion of testicular mass or malignancy[1]
• Emergency department disposition: varicocele itself is not an emergency; however, if acute scrotal pain is the presentation, torsion must be excluded before discharge[1]

18. Follow Up / Return Precautions

• Adolescents: annual follow-up with testicular volume measurement and/or semen analysis (Tanner V) until paternity is achieved[5][12]
• Adults with untreated varicocele and fertility concerns: semen analysis every 1–2 years[5]
• Post-repair: repeat semen analysis at 3–6 months; if no improvement by 6 months, further evaluation warranted[5]

Return precautions (counsel patients to return for)

• Acute onset of severe scrotal pain (torsion concern)
• New hard testicular mass
• Worsening scrotal swelling or pain despite conservative measures
• Constitutional symptoms (weight loss, fever)
• Expected course: most varicoceles are stable and benign; surgical repair, when indicated, has a low complication rate and is associated with improvement in semen parameters in the majority of patients[5]

References

1. Scrotal Masses. — Langan RC, Puente MEE. American Family Physician. 2022.

2. Effect of Varicoceles on Spermatogenesis. — Kang C, Punjani N, Lee RK, Li PS, Goldstein M. Seminars in Cell & Developmental Biology. 2022.

3. Surgical or Radiological Treatment for Varicoceles in Subfertile Men. — Persad E, O'Loughlin CA, Kaur S, et al. The Cochrane Database of Systematic Reviews. 2021.

4. Inguinal Hernias: Diagnosis and Management. — Shakil A, Aparicio K, Barta E, Munez K. American Family Physician. 2020.

5. Report on Varicocele and Infertility: A Committee Opinion. — Fertility and Sterility. 2014.

6. Management and Treatment of Varicocele in Children and Adolescents: An Endocrinologic Perspective. — Cannarella R, Calogero AE, Condorelli RA, et al. Journal of Clinical Medicine. 2019.

7. Adolescent Varicocele: A Surgical Conundrum. — Beland LE, Davis MF, Aiyar S, et al. Fertility and Sterility. 2026.

8. Recent Trends in the Management of Varicocele. — Takács T, Szabó A, Kopa Z. Journal of Clinical Medicine. 2025.

9. Imaging of the Acute Scrotum: Keys to a Rapid Diagnosis of Acute Scrotal Disorders. — Sweet DE, Feldman MK, Remer EM. Abdominal Radiology. 2020.

10. ACR Appropriateness Criteria® Newly Diagnosed Palpable Scrotal Abnormality. — Khatri G, Bhosale PR, Robbins JB, et al. Journal of the American College of Radiology : JACR. 2022.

11. Diagnosis and Treatment of Infertility in Men: AUA/­ASRM Guideline Part II. — Schlegel PN, Sigman M, Collura B, et al. Fertility and Sterility. 2021.

12. Evaluation and Management of the Adolescent Varicocele. — Kolon TF. The Journal of Urology. 2015.

13. Evaluation of Scrotal Masses. — Crawford P, Crop JA. American Family Physician. 2014.