A varicocele is an enlargement of the veins that carry blood away from the testicle – the so-called pampiniform plexus in the spermatic cord. In roughly nine out of ten cases the varicocele is on the left, which is explained by the anatomy of the left testicular vein.
The condition is common – it affects roughly one in every six or seven men and in many cases causes no symptoms. It matters because it can cause heaviness and pain in the scrotum and is the most common correctable cause of reduced sperm quality. Dr Penev diagnoses varicocele with an ultrasound scan at his practice in Plovdiv and, when indicated, performs surgical treatment at Kaspela University Hospital (UMBAL Kaspela), Plovdiv.
What a varicocele is
On the left, the testicular vein is longer and drains into the left kidney vein, almost at a right angle – hence the higher pressure and the tendency for blood to flow backwards. When the valves in the veins fail, the veins above the testicle become enlarged, blood pools and the temperature in the scrotum rises – and it is this that harms sperm production.
It is graded by how marked it is: subclinical (visible only on ultrasound), grade 1 (can be felt only when straining while standing), grade 2 (can be felt easily without straining) and grade 3 (visible through the skin as a soft, irregular lump).
Symptoms
- heaviness, a dull ache or a dragging feeling in the scrotum that gets worse after standing for a long time or physical exertion and eases when lying down;
- visible or palpable enlarged veins above the testicle, most often on the left;
- a smaller and softer testicle on the affected side;
- in teenagers – the testicle on that side lagging behind in growth;
- difficulty conceiving or abnormal semen analysis results with no other visible cause.
When it is urgent: sudden, severe pain in the testicle, especially with nausea and swelling, is not caused by a varicocele – it may be testicular torsion, where every hour counts. Go to an emergency department or call 112 (the European emergency number). A varicocele that appears quickly in a man over forty, or only on the right, also needs an examination without delay – it may be a sign of a process in the abdomen pressing on the veins.
Causes and risk factors
The main cause is an inborn weakness of the valves in the testicular vein combined with the anatomy of the left side. Being tall, growing quickly during puberty, heavy physical work and standing for long periods all contribute.
Diagnosis
A consultation with Dr Penev begins with a conversation about your symptoms and your plans to have children. The scrotum is examined lying down and standing up, while straining – this establishes the grade and side of the varicocele, and the size of the two testicles is compared.
The key test is an ultrasound scan of the scrotum, which measures the diameter of the veins, the backward blood flow when straining and the exact volume of the testicles. Men who want children are given a semen analysis and, if needed, hormone tests. With a right-sided or atypical varicocele, an ultrasound of the abdomen and kidneys is also done. A hard lump in the testicle itself is a separate problem – see the article on a testicular lump.
Treatment
Not every varicocele needs treatment: one that causes no symptoms, with a normal semen analysis and normal testicle size, is monitored – with regular examinations and ultrasound scans, and in teenagers a yearly check of testicle growth. For mild heaviness, supportive underwear and avoiding standing for long periods and overheating help.
Treatment is recommended for:
- pain or heaviness that does not respond to conservative measures;
- abnormal semen analysis results in a couple who are having difficulty conceiving with no other explainable cause;
- teenagers whose affected testicle is lagging behind in size.
The aim of surgery is to tie off the enlarged veins while preserving the artery and lymphatic vessels of the testicle. The most widely used methods are microsurgical ligation through a small incision in the groin, laparoscopic ligation, which is suitable for a varicocele on both sides, and embolisation, in which the veins are blocked from the inside through a catheter. Dr Penev discusses the right method with you; operations on the scrotum and spermatic cord are performed at Kaspela University Hospital, most often as a day case.
Possible complications – hydrocele (fluid around the testicle), recurrence and, very rarely, damage to the artery – are uncommon with modern techniques. Surgery improves sperm parameters in some men, but it is not a guarantee of pregnancy and is always considered together with the test results of both partners – more in the article on male infertility.
When to see a urologist
Book a consultation if you feel heaviness or pain in the scrotum, if you can feel enlarged veins or one testicle seems smaller, if you are the parent of a teenager with such a finding, or if you and your partner have been trying to conceive for more than a year without success.
Prevention
A varicocele cannot be prevented, because it is caused by inborn features of the veins. You can, however, limit the symptoms by avoiding prolonged overheating of the scrotum and not putting off an examination when new heaviness appears.
A varicocele is a common and, in most cases, harmless condition, but when it hurts or affects fertility, there is effective treatment. Book an appointment with Dr Penev in Plovdiv or Karlovo for an ultrasound examination and an individual assessment.
Frequently asked questions
Can a varicocele go away on its own?
No. Once enlarged, the veins do not return to their normal size. A small varicocele, however, often stays the same for years and needs no treatment, only monitoring.
Does a varicocele affect erections and testosterone?
It does not affect erections directly. In some men with a larger varicocele the testosterone level is slightly lower; whether surgery improves it is assessed individually, because the evidence is limited.
How long after surgery does the semen analysis improve?
Sperm take about three months to develop, so the follow-up semen analysis is done three to six months after the operation. Improvement is seen in some men, but not in all.
Can I play sport with a varicocele?
Yes, sport does not make a varicocele worse. If you feel heaviness, supportive underwear during exercise helps. The only restrictions are after surgery – about a month without heavy physical exertion.
Can a varicocele be treated without surgery?
Enlarged veins do not shrink with medicines or exercises. Conservative measures ease the heaviness, and when treatment is indicated, the lasting options are surgically tying off the veins or embolisation (blocking the veins from the inside).
The information on this website is for general education and does not replace an examination and consultation with a doctor. If you have urgent symptoms, seek medical help immediately or call 112.