AUA Summit - What are Varicoceles?


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What are Varicoceles?

A varicocele is when veins become enlarged inside your scrotum (the pouch of skin that holds your testicles). These veins are called the pampiniform plexus. Out of 100 males, 10 to 15 have varicocele. It is like getting a varicose vein in your leg.

Varicoceles are when the pampiniform plexus veins in the scrotum become enlarged. These veins are like varicose veins (twisted, swollen veins found in the leg.) Varicoceles form during puberty. They can grow larger, and you may notice them more over time. Varicoceles are more common on the left side of the scrotum. This is because the male anatomy is not the same on both sides. Varicoceles can exist on both sides at the same time, but this is rare. About 10 to 15 boys out of 100 have a varicocele.

Most of the time, varicoceles cause no problems and are harmless. Less often varicoceles can cause pain, problems fathering a child or one testicle to grow slower or shrink.

What Happens Normally?

The male reproductive system makes, stores and moves sperm. The scrotum is the sac of skin that holds the testicles (testes). Sperm and the hormone testosterone are made in the testicles. Sperm mature while moving through a coiled tube (the epididymis) behind each testicle.

Sperm travel to the prostate from each epididymis through a tube called the vas deferens. When you ejaculate, seminal fluid mixes with sperm in the prostate to form semen. The semen travels through the urethra and comes out the end of your penis.

The spermatic cord holds the vas deferens and the testicular artery, which brings blood to the testicle. It also houses the pampiniform plexus, a group of veins that drain the blood from the testicles. Testes need a certain body heat that is below our core body heat for optimal sperm production, maturity and function. The body heat in the scrotum is about five degrees lower than that of the belly or pelvis. The latter is due to the presence of pampiniform plexus, which act as a countercurrent heat exchanger, cooling blood in the testicular artery before it enters the testicles. This helps keep the testes at the body heat needed to make good quality sperms. When these veins become enlarged such as in varicocele, overheating of the testes can lower sperm production and function, which may affect fertility.


Most males with a varicocele have no symptoms. But varicoceles are a concern for many reasons. Some may cause infertility (problems fathering a child) and slow growth of the left testicle during puberty. Varicoceles may be the cause of fertility problems in about four out of ten men who have problems fathering their first child. They may also be the cause of fertility problems in about eight out of ten men who have problems fathering a child after their first.


There may be many causes of varicoceles. The valves in the veins may not work well (or may be missing). If blood flow is sluggish, blood may pool in the veins. Also, the larger veins moving from the testicles towards the heart are connected differently on the left and right sides. More pressure is needed on the left side to keep blood flowing through the veins towards the heart. If blood flows backwards or pools in the veins, that can cause veins to swell. Rarely, swollen lymph nodes or other masses behind the belly block blood flow. This can lead to sudden swelling of the scrotal veins. This is often painful.

Are Varicoceles Common?

About 15 out of 100 men have varicoceles. It is hard to predict which of these 15 will have fertility problems caused by their varicocele. But about 4 in 10 men tested for fertility problems have a varicocele and decreased sperm movement. There is no link with other defects, race, place of birth or ethnic group. Though varicoceles are often found in men tested for infertility, 8 out of 10 men who have a varicocele do not have fertility problems.


Varicoceles are found through self-exam of the scrotum or during a routine doctor’s exam. They have been described as a “bag of worms” because of how they look and feel.

Urologists often check for varicoceles with the patient standing. You may be asked to take a deep breath, hold it and bear down while your urologist feels the scrotum above the testicle. This technique is known as the “Valsalva maneuver.” It lets your urologist find any enlarged veins.

Your urologist may order a scrotal ultrasound test. Ultrasound uses sound waves to make a picture of what’s inside your body. Signs of varicoceles on ultrasound are veins wider than 3 millimeters with blood flowing the wrong way during the Valsalva maneuver. The ultrasound can also show the size of the testicles. This is useful in deciding how to treat teens. An ultrasound is not needed if problems are not felt during the physical exam.


Often, varicoceles are not treated. Treatment is offered for males who have:

  • fertility problems (problems fathering a child)
  • pain
  • the left testicle growing more slowly than the right
  • abnormal semen analysis

There are no drugs to treat or prevent varicoceles. But pain killers (such as acetaminophen or ibuprofen) may help with pain.

When needed, surgery is the main form of treatment. Embolization (briefly blocking the veins) is a non-surgical treatment option.


There are many ways to do varicocele surgery. All involve blocking the blood flow in the pampiniform plexus veins.

Surgery is done under general anesthesia. The two most common surgeries are:

  • Microscopic varicocelectomy: With this technique, the surgeon makes a 1 cm cut above the scrotum. Using the microscope, the surgeon ties off all small veins, but avoids the vas deferens, testicular artery and lymphatic drainage. The procedure takes 2 to 3 hours, and the patient goes home on the same day.
  • Laparoscopic varicocelectomy: With this technique, the surgeon inserts thin tubes in the abdomen and performs vein ligation. This procedure is shorter and takes about 30-40 minutes. Patient returns home on the same day.
Surgery Results

Since surgeons have started using smaller cuts through the muscle for open surgery, healing time and pain are about the same with microscopic and laparoscopic surgery. Problems after either surgery are rare. Some problems could include:

  • varicocele remaining (persistence) or coming back (recurrence)
  • fluid forming around the testicle (hydrocele)
  • injury to the testicular artery

There is a small chance surgery won't fix the problem. In rare cases, injury to the testicular artery can lead to loss of the testicle. Persistence or recurrence of the varicocele happens in less than one of ten patients who have surgery. Microscopic surgery has the lowest persistence rate or chance of varicocele coming back.

Most of the time, patients return to normal activities after one week with little pain.

Percutaneous Embolization

Embolization is done by an Interventional Radiologist. Injection of contrast through a tube with x-ray guidance is used to see the source of the problem. The goal is to find all veins leading to the varicocele. Coils (plugs with or without sclerosant, a dehydrating drug) are used to block the blood flow to the varicocele. It is done either with local anesthetic or with light sedation through a very small hole in the groin or neck. The method most often takes 45 minutes to an hour. Some problems are:

  • varicocele remaining (persistence) or coming back (recurrence)
  • the coil moving from where it was placed
  • a chance of infection where the tube was placed

After Treatment

Healing after surgery is fast and pain is often mild. You should not work out for 10 to 14 days. You can often return to work 5 to 7 days after surgery. You will also follow-up with your urologist. For surgery done for fertility problems, semen analysis is done three to four months later.

Healing after embolization is also relatively short with only mild pain. You should not work out for 7 to 10 days after the procedure. You can often return to work one to two days later. The recurrence rate with embolization is on par with surgery. There are cases where embolization is preferred over surgery.

The impact of varicocele repair on fertility isn’t clear. Some studies show fertility gets better after varicocele repair while other studies don’t. Semen quality gets better in about 6 out of 10 infertile men after varicocele repair. Varicocele treatment should be considered about along with other fertility treatment choices.

In teens, where the main reason for surgery is slow testicular growth, catch-up growth may or may not happen.

Frequently Asked Questions

What will happen if I choose not to be treated?

Most males with varicocele will not have problems. One out of five males with varicocele will have trouble fathering children. Semen analysis is highly recommended after age 16 years to determine if varicocele repair is needed. If a semen analysis is normal, it is recommended to have a repeat analysis every 2 to 3 years as the quality of sperms may go down with time. Fertility issues may come up years later, even if not seen earlier.

My teenage son was diagnosed with a varicocele. Should this be fixed?

Treatment of teens depends on each case. It is of great value to talk about choices with an adult or pediatric urologist. Varicocele repair in a teen may be a good choice if there is pain, if one testicle is much smaller than the other or the teen has an abnormal semen analysis at age 16 years. Some choose repair so they won't have to worry about fertility issues in the future. Semen analyses can be done in older teens to see if repair would help.

I have no symptoms, but wish to have children. Should I have my varicocele repaired?

As a rule, varicoceles with no symptoms are not repaired. Most doctors do not believe these varicoceles cause health problems if not treated. If there's worry about fertility, semen analysis can be done to see if the varicocele is harming sperm quality.

I have pain with my varicocele. What can I do to ease the pain?

Supporting the scrotum with a jockstrap or briefs-style underwear can help varicocele pain. Lying on your back helps the varicocele drain and often eases pain. Taking pain killers (such as acetaminophen and ibuprofen) may help. You can also talk with your doctor about varicocele repair.

I am thinking about having my varicocele repaired for fertility reasons. How long will I have to wait to see if my semen quality gets better?

Semen analyses are often done three to four months after the procedure. Semen quality often gets better within six months, but it may also take as long as a year.

I found a lump on my scrotum during a self-exam. Should I worry?

Abnormalities in the male reproductive tract may show up as a mass in the scrotum. Masses could be nothing to worry about and may have little effect on your health. Or they could be a sign of life-threatening illness. It is of great value to find out what is causing your mass. One type of mass may be testicular cancer. This would be cause for concern and calls for quick action. It's vital to see a doctor when you find any lump or bump in your testicle.

Updated October 2022.

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