VaricoceleMANAGEMENT

GENITOURINARY AND REPRODUCTIVE PRESENTATIONS · 12 SECTIONS

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567 items

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Acute Kidney Injury (ATN)Acute Kidney Injury (Post-renal)Acute Kidney Injury (Pre-renal)Amniotic Fluid Embolism Balanitis Bladder Rupture Breast Abscess Cystitis Dialysis access complications Ectopic pregnancy Epididymitis Glomerulonephritis Hematuria (gross)Hydrocele Interstitial Cystitis Mastitis Mittelschmerz Nephrolithiasis Nephrotic Syndrome Flare Nutcracker Syndrome Orchitis Ovarian Cyst Rupture Ovarian hyperstimulation syndrome Ovarian torsion Paraphimosis Pelvic Congestion Syndrome Pelvic Inflammatory Disease (PID)Peritoneal dialysis peritonitis Phimosis Priapism Prostatitis Pyelonephritis Renal laceration Renal transplant complications and rejection Ruptured ovarian cyst Testicular torsion Torsion of Appendix Testis Tubo-ovarian abscess Ureteral Rupture Urethritis Urinary Retention Urinary tract infection (uncomplicated)Urolithiasis (renal colic)Vaginal bleeding (non-pregnant)Vaginitis (Bacterial)Vaginitis (Candidal)Varicocele Vulvovaginal Hematoma

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp37

Immediate priorities

›Acute scrotal pain triage

›Testicular torsion must be excluded before managing varicocele

›Salvage rate approximately 90% if detorsion within 6 hours

›If torsion suspected, emergent urology consult and surgical exploration

›Absent cremasteric reflex is the most reliable torsion sign

›Do not delay surgical exploration awaiting imaging if torsion is clinically likely

›TWIST score can risk-stratify when diagnosis is uncertain

›Red flag screening

›Isolated right-sided varicocele

›Suggests retroperitoneal mass or IVC obstruction

›CT abdomen/pelvis required to exclude renal cell carcinoma

›New-onset varicocele in men over 40 years

›Retroperitoneal or pelvic malignancy must be excluded

›Varicocele that does not decompress supine confirms venous obstruction

›Hard non-tender intratesticular mass

›Testicular cancer concern

›Tumor marker panel required

›Constitutional symptoms with scrotal abnormality

›Weight loss, fever, night sweats prompt malignancy workup

›Scrotal ultrasound and CT abdomen/pelvis indicated

Monitoring and escalation

›Disposition decision points

›Varicocele alone is not an emergency

›Outpatient urology referral is appropriate for the vast majority

›Emergency evaluation is required only when torsion or malignancy cannot be excluded

›Escalation triggers

›Failure to exclude testicular torsion requires immediate surgical consultation

02History/hx50

Presenting symptoms

›Scrotal symptoms

›Most varicoceles are asymptomatic and found incidentally

›Prevalence 15% of all men

›Prevalence 35% in men with primary infertility

›Dull ache or scrotal heaviness

›Worse with prolonged standing or exertion

›Improved with recumbency

›Acute severe scrotal pain

›Torsion must be excluded

›Varicocele does not typically cause acute severe pain

Reproductive history

›Fertility concerns

›Duration of attempting conception

›Partner fertility status

›Prior pregnancies or fertility evaluations

›Prior semen analysis results

›Count, motility, morphology

›Sperm DNA fragmentation testing emerging but not routine

›Hypogonadal symptoms

›Fatigue and decreased energy

›Larger varicoceles may impact testosterone production

Alarm features

›Features requiring urgent evaluation

›Isolated right-sided or bilateral scrotal swelling with rapid onset

›Secondary varicocele from retroperitoneal obstruction must be excluded

›Varicocele not decompressing supine confirms obstruction

›New-onset varicocele in older men over 40 years

03Physical Exam/exam50

Scrotal examination technique

›Examination positioning

›Patient examined standing in a warm room

›Warmth allows scrotal relaxation for accurate palpation

›Both hemiscrotums inspected and palpated

›Valsalva maneuver

›Varicocele increases in size with Valsalva

›Decompresses when patient moves to supine position

›Classic palpation finding

›Bag of worms texture above and posterior to the testis

›Pampiniform plexus dilation palpable along spermatic cord

WHO grading

›Clinical grading system

›Grade I

›Palpable only with Valsalva maneuver

›Not visible or palpable at rest

›Grade II

›Palpable at rest in upright position

›Not visible

›Grade III

›Visible at rest in upright position

›No Valsalva required for detection

Testicular assessment

›Testicular size and quality

›Bilateral testicular volume measurement

›Orchidometer or ultrasound volumetry

›Ipsilateral testicular atrophy suggests varicocele-related damage

›Volume asymmetry threshold

04Differential Diagnosis/ddx36

Life-threatening mimics

›Acute scrotal emergencies

›Testicular torsion

›ICD-10 N44.00

›Acute severe pain, high-riding testis, absent cremasteric reflex

›Testicular cancer

›ICD-10 C62.9

›Firm non-tender unilateral intratesticular mass, does not transilluminate

›Fournier gangrene

›ICD-10 N49.3

›Rapidly progressive necrotizing fasciitis of perineum and genitalia

Common scrotal mass differentials

›Benign scrotal masses

›Hydrocele

›ICD-10 N43.3

›Painless smooth fluctuant mass, transilluminates, extratesticular

›Spermatocele or epididymal cyst

›ICD-10 N43.40

›Painless cystic mass at head of epididymis, transilluminates

›Epididymitis

›ICD-10 N45.1

›Painful gradual onset, tenderness over epididymis, positive Prehn sign, often infectious

›Torsion of testicular appendage

›ICD-10 N44.03

›Gradual onset superior pole pain, blue dot sign

›Inguinal hernia extending into scrotum

›ICD-10 K40.90

›Reducible mass, palpable Valsalva impulse, extends into inguinal canal

05Laboratory Tests/lt37

Fertility evaluation labs

›Semen analysis

›Minimum two analyses required for diagnostic accuracy

›Parameters assessed: sperm count, motility, morphology

›Sperm DNA fragmentation testing emerging but not yet routine

›Reference thresholds

›WHO 2021 reference values for normal semen parameters

›Oligozoospermia, asthenozoospermia, teratozoospermia defined by WHO criteria

Hormonal assessment

›Gonadotropin and androgen panel

›FSH

›Elevated FSH indicates impaired spermatogenesis

›Helps distinguish obstructive from non-obstructive cause

›LH and total testosterone

›To evaluate for secondary hypogonadism

›Larger varicoceles associated with reduced testosterone production

›Inhibin B

›Marker of Sertoli cell function

›Research setting; not routine clinical practice

Tumor markers

›Testicular cancer markers

›AFP (alpha-fetoprotein)

›Elevated in non-seminomatous germ cell tumors

›Baseline required before orchiectomy

›Beta-hCG

›Elevated in choriocarcinoma and mixed germ cell tumors

›Can cause gynecomastia

›LDH

06Diagnostic Tests/dt58

Scoring Systems

›TWIST score

›Testicular Workup for Ischemia and Suspected Torsion

›Variables: testis swelling, hard testis, absent cremasteric reflex, nausea/vomiting, high-riding testis

›Score 0 to 7 points total

›Risk stratification

›Low risk (0 to 2): low probability of torsion, further evaluation warranted

›Intermediate risk (3 to 4): additional imaging with Doppler ultrasound

›High risk (5 to 7): immediate surgical exploration without imaging delay

›WHO varicocele grading

›Grades I through III based on physical examination findings

›Grade I palpable only with Valsalva

›Grade II palpable at rest

›Grade III visible at rest

›Clinical correlation

›Grade influences treatment decision alongside semen parameters and volume asymmetry

›Subclinical varicocele not palpable by definition and not an indication for treatment

MRI

›MRI scrotal indications

›Not first-line for varicocele evaluation

›Reserved for inconclusive ultrasound findings

›Superior soft tissue characterization for complex scrotal masses

›MRI abdomen and pelvis for retroperitoneal evaluation

›Alternative to CT when radiation avoidance is preferred

›Superior for detecting venous anatomy and soft tissue masses

›MRI venography

›Can delineate internal spermatic vein anatomy pre-operatively

›Used in planning percutaneous embolization in complex cases

07Disposition/dispo33

Emergency department discharge

›Criteria for discharge from emergency setting

›Varicocele alone is not an emergency

›Outpatient urology referral appropriate for vast majority

›Routine labs and scrotal ultrasound as indicated can be arranged outpatient

›Testicular torsion must be excluded before discharge from ED

›Clinical exam and Doppler ultrasound if torsion is uncertain

›Do not discharge if TWIST score intermediate or high

Urology referral indications

›Indications for outpatient urology referral

›Palpable varicocele with known infertility and abnormal semen parameters

›Female partner with normal or treatable fertility required per AUA/ASRM guidelines

›Fertility and Sterility Committee Opinion 2014; AUA/ASRM Guideline Part II 2021

›Symptomatic varicocele refractory to conservative measures

›Pain persisting despite NSAIDs and scrotal support

›Significantly impacts quality of life

›Adolescent with testicular volume asymmetry greater than or equal to 20%

›Or abnormal semen analysis at Tanner V

›Beland et al. Fertility and Sterility 2026; Kolon. J Urology 2015

›Isolated right-sided varicocele after retroperitoneal imaging

›After secondary cause excluded

›Urology evaluation for definitive management

›Suspicion of testicular mass or malignancy

›Urgent referral rather than routine

›Tumor markers and scrotal ultrasound prior to referral

Follow-up framework

›Follow-up intervals

›Adolescents with untreated varicocele

08Treatment/t88

Conservative management

›First-line non-surgical approach

›Indications for conservative management

›Asymptomatic varicocele with normal semen parameters

›Subclinical varicocele regardless of fertility status

›Scrotal support

›Supportive underwear reduces venous pooling

›Simple and effective for symptomatic relief

›Activity modification

›Avoidance of prolonged standing when symptomatic

›Avoidance of excessive scrotal heat exposure

›Antioxidant supplementation

›Vitamin C, Vitamin E, CoQ10 studied in fertility context

›Insufficient evidence for routine recommendation

Analgesic therapy

›Pharmacologic symptom management

›NSAIDs first line

›Ibuprofen 400 to 600 mg orally every 6 to 8 hours

›With food to reduce gastrointestinal side effects

›Avoid in renal impairment or peptic ulcer disease

›Naproxen 250 to 500 mg orally every 8 to 12 hours

›Longer half-life allows twice daily dosing

›Renal and hepatic caution applies

›Acetaminophen alternative

›500 to 1000 mg orally every 4 to 6 hours

›Maximum 4000 mg per 24 hours in healthy adults

›Reduce to 2000 mg per 24 hours in hepatic impairment or chronic alcohol use

›No role for empiric antibiotics unless epididymitis is clinically suspected

›Do not treat varicocele pain with antibiotics

›Antibiotic selection guided by STI risk and age if epididymitis confirmed

Varicocele repair indications

›AUA/ASRM criteria for repair

›Infertility indication

›Palpable varicocele

›Plus documented infertility

›Plus abnormal semen parameters

›Female partner with normal or surgically correctable fertility

›Class I recommendation per AUA/ASRM Guideline Part II 2021

›Cochrane 2021 systematic review supports treatment benefit in subfertile men

›Pain indication

›Symptomatic varicocele refractory to conservative measures

›No specific grading required

›Urology to confirm diagnosis and confirm no alternative cause

›Adolescent indication

›Ipsilateral testicular volume loss greater than or equal to 20% asymmetry

›Or abnormal semen analysis

›Urology referral for individualized decision

Repair not indicated

›Contraindications to varicocele repair

›Subclinical varicocele

›Non-palpable varicocele found incidentally on imaging

›No evidence of benefit; AUA/ASRM Guideline Part II 2021

›Normal semen parameters

›Repair does not further improve fertility in men with normal semen

›Watchful waiting appropriate

›Isolated teratozoospermia

›Abnormal morphology alone is not a sufficient indication

›AUA/ASRM Guideline Part II 2021

Surgical options

›Microsurgical subinguinal varicocelectomy

›Gold standard surgical approach

›Lowest recurrence rate approximately 1%

›Lowest hydrocele and arterial injury complication rates

›Technical requirements

›Requires intraoperative optical magnification

›Identification and preservation of testicular artery and lymphatics

›Expected outcomes

›Improvement in semen parameters in majority of treated patients

›Spontaneous pregnancy rates improve post-repair

›Time to improvement in semen parameters approximately 3 to 6 months

›Inguinal microsurgical approach

›Similar outcomes to subinguinal approach

›Slightly higher ligation point

›Preferred in some centers based on surgeon expertise

›Recurrence and complication rates comparable to subinguinal

›Takacs et al. Journal of Clinical Medicine 2025 review

›Laparoscopic varicocelectomy

›Minimally invasive option

›Higher recurrence than microsurgical approaches

›General anesthesia required

›May be preferred for bilateral repair

›Single abdominal access point

›Not first-line due to higher recurrence

›Percutaneous embolization

›Minimally invasive radiological alternative

›Comparable efficacy to surgical approaches in eligible patients

›Local or sedation anesthesia acceptable

›Technique

›Catheter-directed coil or sclerosant embolization of internal spermatic vein

›Performed by interventional radiology

›Preferred in recurrent or persistent varicocele post-surgical repair

›Spermatic venography guides catheter placement

›Fertility and Sterility Committee Opinion 2014

09Special Populations/sp42

Pregnancy

›Varicocele in female patients

›Varicocele is a male-specific condition affecting testicular venous plexus

›Female partners of affected men should be evaluated for ovulatory and tubal factors

›AUA/ASRM Guideline Part II 2021 requires female partner assessment before repair

›Pelvic varicocele in women

›Distinct entity: ovarian vein reflux causing pelvic congestion syndrome

›ICD-10 N94.89 pelvic pain

›Treated by interventional radiology embolization, not same as scrotal varicocele

›Not covered by scrotal varicocele management pathway

Geriatric

›Varicocele in older men

›New-onset varicocele in men over 40 years is a red flag

›Must exclude secondary cause including retroperitoneal malignancy

›CT abdomen/pelvis mandatory

›Fertility considerations in older men

›Advanced paternal age associated with decreased fertility and increased genetic risk

›ART with ICSI may be more appropriate than varicocele repair depending on female partner age

›Surgical risk considerations

›Microsurgical repair generally well-tolerated

›Cardiovascular and anesthetic risk assessment for any surgical approach

›Percutaneous embolization preferred in high surgical risk patients

Pediatrics

›Adolescent varicocele

›Prevalence increases with puberty onset

›Approximately 15% of adolescent males by late puberty

›Cannarella et al. Journal of Clinical Medicine 2019

›Monitoring protocol

10Background/b69

Epidemiology

›Prevalence and demographics

›General male population

›Approximately 15% of all men have varicocele

›Left-sided in 85 to 90% of cases due to left gonadal vein anatomy

›Infertility population

›35% prevalence in men with primary infertility

›Up to 80% prevalence in men with secondary infertility

›Langan and Puente. American Family Physician 2022

›Age of onset

›Peak onset 15 to 25 years corresponding to puberty

›Varicoceles are uncommon before puberty

›Bilateral varicocele

›Less common; bilateral disease may suggest venous obstruction from secondary cause

›Right-sided alone is rare and mandates secondary workup

Pathophysiology

›Venous anatomy and failure

›Left testicular vein anatomy

›Drains into left renal vein at right angle creating higher hydrostatic pressure

›Right testicular vein drains directly into IVC at an oblique angle

›Venous valve insufficiency

›Incompetent or absent valves allow retrograde blood flow

›Pampiniform plexus dilates in response to increased venous pressure

›Spermatogenic impairment mechanisms

›Scrotal hyperthermia from increased venous blood

›Normal testicular temperature 2 to 4 degrees Celsius below core body temperature

›Kang et al. Seminars in Cell and Developmental Biology 2022

›Reflux of adrenal and renal metabolites via left renal vein

›Catecholamines and cortisol toxic to spermatogenesis

›Testicular hypoxia from venous stasis

›Impairs oxidative phosphorylation and Sertoli cell function

›Increased reactive oxygen species

›Sperm DNA fragmentation results

›Impairs sperm motility and fertilization capacity

›Hormonal effects

›Leydig cell dysfunction

›Reduced testosterone production in larger or bilateral varicoceles

›Elevated LH with normal or low testosterone suggests compensated hypogonadism

›Sertoli cell dysfunction

›Elevated FSH reflects impaired spermatogenesis

›Reduced inhibin B in severe cases

Therapeutic Considerations

›Evidence base for treatment

›Cochrane 2021 systematic review

›Surgical or radiological treatment improves pregnancy rates in subfertile men with palpable varicocele

›Persad et al. Cochrane Database of Systematic Reviews 2021

›AUA/ASRM Guideline Part II 2021

›Repair indicated only for palpable varicocele with infertility and abnormal semen parameters

›Subclinical varicocele repair is not recommended

›Fertility and Sterility Committee Opinion 2014

›Foundational guideline for varicocele and infertility management

›Requires female partner evaluation before recommending repair

›Treatment expectations

›Semen parameter improvement

›Improvement in sperm count, motility, and morphology in majority post-repair

›Time to measurable improvement approximately 3 to 6 months

›Spontaneous pregnancy

›Improved spontaneous pregnancy rates with surgical repair vs. observation

›ART success rates also improve post-repair in some studies

›Testosterone recovery

›Some improvement in testosterone levels post-repair in hypogonadal men

›Not a primary indication for repair in absence of infertility

›Repair technique comparison

›Microsurgical subinguinal varicocelectomy

›Gold standard: lowest recurrence approximately 1%, lowest hydrocele rate

›Inguinal microsurgical: similar outcomes

›Laparoscopic varicocelectomy

›Higher recurrence than microsurgical approaches

›Not preferred as first-line

›Percutaneous embolization

›Comparable efficacy to surgical approaches

›Preferred for recurrent varicocele post-surgery

11Patient Discharge Instructions/pdi32

copy discharge instructions

›Diagnosis and explanation

›You have been evaluated for a varicocele, which is an enlargement of the veins within the scrotum

›This is a common condition affecting approximately 15% of men

›It is not dangerous on its own but may affect fertility in some men

›Most varicoceles do not require immediate treatment

›Your doctor will refer you to a urologist if treatment is needed

›Treatment decisions are based on symptoms, fertility goals, and testicular size

›Activity and self-care

›Wear supportive underwear to reduce scrotal discomfort

›Avoid prolonged standing when pain is present

›Avoid excessive heat exposure to the scrotum

›Pain management at home

›Ibuprofen 400 to 600 mg every 6 to 8 hours with food as needed for pain

›Acetaminophen 500 to 1000 mg every 6 hours as alternative

›Return to emergency department immediately if

›Sudden severe testicular pain develops

›This may be a sign of testicular torsion, a surgical emergency

›Do not wait until morning; seek emergency care immediately

›New hard lump develops in the testicle

›May indicate testicular cancer

›Requires urgent evaluation

›Scrotal swelling rapidly worsens or becomes red and hot

›May indicate infection or serious condition

›Weight loss, night sweats, or fever develop

›May indicate an underlying malignancy

›Follow-up instructions

›Attend your urology referral appointment as arranged

12References/r35

Guidelines and key sources

›Primary clinical guidelines

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

›AUA/ASRM criteria for varicocele repair in infertile men

›Subclinical varicocele repair not recommended

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

›Foundational guideline for varicocele and fertility evaluation

›Requires female partner assessment before recommending repair

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

›Supports treatment benefit in subfertile men with palpable varicocele

›Informs surgical vs. radiological approach comparison

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

›Color Doppler ultrasound as first-line imaging

›CT criteria for secondary varicocele evaluation

Supporting references

›Secondary sources

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

›Clinical approach to scrotal mass evaluation

›Alarm features for malignancy and torsion

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

›Pathophysiology of varicocele-induced spermatogenic impairment

›Scrotal hyperthermia and reactive oxygen species mechanisms

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

›Adolescent monitoring and treatment thresholds

›Peak retrograde flow prognostication

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

›Updated adolescent varicocele management guidance

›Takacs T, Szabo A, Kopa Z. Recent Trends in the Management of Varicocele. Journal of Clinical Medicine. 2025

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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