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Roughly 15 percent of all men, and about 40 percent of men evaluated for infertility, have dilated veins in the scrotum that resemble varicose veins of the leg. A varicocele is a tangle of enlarged pampiniform plexus veins above and around the testicle, most often on the left side, and it is the single most common identifiable and surgically correctable cause of male infertility. Many varicoceles cause no problems at all; others affect fertility, testicular size, or comfort and warrant evaluation. This guide covers what a varicocele is, how it is diagnosed, and when treatment makes sense.
Important: This article is educational and is not a substitute for care from a qualified clinician. A varicocele should be diagnosed and graded by a physician, and decisions about treatment depend on your symptoms, fertility goals, and semen analysis. Do not self-diagnose scrotal swelling. Sudden, severe testicular pain can signal testicular torsion, a surgical emergency — call 911 or go to the nearest emergency room if that occurs.
What a Varicocele Is
The pampiniform plexus is a network of small veins in the spermatic cord that helps regulate testicular temperature. When valves in these veins fail, blood pools and the veins dilate, much like varicose veins in the legs. The left side accounts for about 85 percent of varicoceles, partly because the left testicular vein drains at a right angle into the left renal vein, creating higher pressure and a longer column of blood. Bilateral varicoceles occur in roughly 15 to 20 percent of cases. Isolated right-sided varicoceles are uncommon and prompt evaluation for a retroperitoneal mass blocking venous return.
The Urology Care Foundation notes that varicoceles typically appear during puberty and persist through life. They are graded clinically: subclinical (detected only on imaging), Grade 1 (palpable only with the Valsalva maneuver), Grade 2 (palpable at rest), and Grade 3 (visible through the scrotal skin).
Symptoms
Most varicoceles cause no symptoms and are discovered during physical exams or fertility workups. When symptoms do occur, men often describe a dull, aching scrotal heaviness or pain that worsens with prolonged standing, exercise, or warm weather and improves with lying down. The classic exam finding is a “bag of worms” texture above the testicle. Larger varicoceles may be visible through the skin.
Other concerns include testicular atrophy (the affected testicle is smaller than the unaffected side, generally defined as more than 20 percent volume loss or a 2 mL difference) and abnormal semen parameters. In adolescents, a varicocele can impair growth of the testicle on the affected side, which is why teens with a size discrepancy are followed closely.
How Varicocele Affects Fertility
Varicoceles are found in about 40 percent of men with primary infertility and up to 80 percent of men with secondary infertility. The proposed mechanisms include elevated scrotal temperature (which impairs sperm production), oxidative stress, hormonal disruption, and reflux of metabolic byproducts from the renal vein. Semen analysis often shows reduced sperm concentration and motility and abnormal morphology — sometimes called the “stress pattern.”
Not every varicocele causes infertility. Some men with large varicoceles have normal semen parameters and conceive easily; others with subclinical varicoceles have significant fertility problems. The combination of a palpable (clinical) varicocele plus an abnormal semen analysis is what most often justifies intervention. The male infertility guide and semen analysis guide cover the related workup in more detail.
Diagnosis
Physical examination remains the foundation. The patient is examined standing in a warm room, both at rest and during Valsalva. The clinician palpates the spermatic cord above each testicle, feeling for the characteristic dilated veins, and assesses testicular volume by exam or orchidometer.
Scrotal ultrasound with color Doppler confirms the diagnosis and quantifies vein diameter and reflux duration. Veins greater than about 3 mm with reflux during Valsalva are generally considered diagnostic on ultrasound. The medical conditions library includes other scrotal conditions that ultrasound helps distinguish, such as hydrocele and spermatocele.
Semen analysis is recommended for any man with a clinically detectable varicocele who is concerned about fertility, regardless of whether he is currently trying to conceive. Hormonal evaluation (testosterone, FSH, LH) is added when atrophy or symptoms of low testosterone are present.
Treatment Options
Observation
Asymptomatic varicoceles in men with normal semen parameters and no testicular atrophy generally need no treatment. Monitoring with periodic exams and, when relevant, semen analyses is reasonable.
Microsurgical Varicocelectomy
The microsurgical subinguinal approach is widely considered the gold standard for varicocele repair. Using an operating microscope, the surgeon ligates the dilated veins while preserving the testicular artery and lymphatics, which lowers the risk of recurrence and of hydrocele formation. According to outcomes summarized in the AUA/ASRM male infertility guideline, repair improves semen parameters in a majority of appropriately selected men. In the guideline’s pooled analysis, estimated pregnancy rates rose from an assumed baseline of about 17 percent without treatment to roughly 42 percent after subinguinal microsurgical varicocelectomy, with the other surgical and radiologic approaches landing in a similar mid-30s range. Individual results vary with baseline semen quality, female-partner factors, and surgical technique.
Other Surgical Approaches
Open inguinal (Ivanissevich), retroperitoneal (Palomo), and laparoscopic approaches are alternatives, generally reserved for specific anatomic situations. They tend to have higher rates of recurrence and hydrocele formation than microsurgical repair.
Percutaneous Embolization
An interventional radiologist threads a catheter into the testicular vein and occludes it with coils or sclerosing agents. Recovery is faster than open surgery and there is no incision, but technical failure occurs in roughly 10 to 15 percent of cases, and access-related issues can occasionally arise.
When to Treat
Following AUA/ASRM guidance, indications for varicocele repair generally include a clinically palpable varicocele plus one or more of: abnormal semen analysis in a couple attempting conception (in men who are not azoospermic), ipsilateral testicular atrophy, persistent scrotal pain after conservative measures, or documented hypogonadism with a clinical varicocele. Adolescent varicoceles with growth failure of the affected testicle warrant evaluation by pediatric urology. Treatment is a shared decision that weighs the likely benefit against the modest risks of a procedure, and it should be individualized rather than automatic.
When to See a Doctor
New scrotal swelling, persistent dull scrotal pain, visible clusters of veins, or difficulty conceiving warrant urology evaluation. Right-sided varicoceles, particularly new ones in older men, deserve prompt workup to rule out a mass blocking the inferior vena cava.
When to seek emergency care: Call 911 or go to the nearest emergency room if you experience sudden severe testicular pain (testicular torsion is roughly a 6-hour surgical emergency to save the testicle), acute scrotal swelling with redness, or fever with scrotal pain.
Frequently Asked Questions
Will varicocele repair definitely improve fertility?
No procedure is guaranteed. Repair improves semen parameters in a majority of men with a clinical varicocele and abnormal semen analysis, and pooled data show higher pregnancy rates after treatment than with observation. Outcomes depend on baseline semen quality, female-partner factors, and surgical technique, so discuss realistic expectations with your urologist.
Can a varicocele come back after surgery?
Recurrence rates are lowest after microsurgical repair (roughly 1 to 2 percent), higher after non-microsurgical surgery, and in the range of about 5 to 15 percent after embolization. Persistent or recurrent varicoceles can be re-treated.
Does a varicocele affect testosterone?
Some studies show modest improvements in testosterone after repair, most consistently in men who start with low values and have a clinical varicocele. The effect is variable, and repair is not performed for testosterone reasons alone without other indications.
Are there non-surgical ways to fix a varicocele?
Embolization avoids an incision but is still a procedure. Lifestyle measures (supportive underwear, avoiding heat, weight management) may ease symptoms but do not eliminate the dilated veins. There is no proven medication or supplement that cures a varicocele.
Do I need treatment if I have no symptoms?
Usually not. An asymptomatic varicocele with normal semen analysis and no testicular atrophy is typically monitored rather than repaired. Treatment is reserved for pain, fertility concerns with abnormal semen analysis, or testicular growth problems.
What to Do Next
If you have a varicocele identified on exam or ultrasound, the next step depends on whether it causes symptoms, affects fertility, or has caused testicular atrophy. Asymptomatic varicoceles with normal semen analysis often need only monitoring. Symptomatic or fertility-related cases warrant a discussion with a urologist who performs microsurgical varicocelectomy regularly, so that the right approach is matched to the right patient. Outcomes are best when treatment is chosen deliberately, based on a full exam, ultrasound, and — where fertility is a concern — a semen analysis.