A varicocele is the most common correctable cause of male infertility. It is usually left-sided and asymptomatic, found incidentally or during an infertility work-up, and the central management question is whether the testis is being harmed enough to justify repair.
Background
A varicocele is the abnormal dilation and tortuosity of the gonadal (internal spermatic) veins of the pampiniform plexus.
Epidemiology
- Found in ≈15% of the general population, 35% of men with primary infertility, and 75–81% of men with secondary infertility.
- The prevalence of clinically diagnosed varicocele in adolescents (8–16%) is similar to that in adults (15%).
- Adolescent varicocele may contribute significantly to the risk of subfertility in adulthood.
Pathogenesis
The primary factors are increased venous pressure in the left renal vein, valvular incompetence of the gonadal vein at its junction with the left renal vein, and collateral venous anastomoses. The nutcracker phenomenon — compression of the left renal vein between the aorta and superior mesenteric artery — may account for the varicocele in some boys, and a tall, thin (low-BMI) body habitus is associated with varicoceles. Solitary right varicoceles are rare; an abrupt-onset right varicocele should prompt evaluation for retroperitoneal pathology such as tumour.
Grading
| Grade | Findings |
|---|---|
| 0 (subclinical) | Non-palpable; visualised only on colour-Doppler ultrasound |
| 1 | Palpable only with Valsalva; not visible |
| 2 | Easily palpable; not visible |
| 3 | Visible on inspection |
Associated Effects
A varicocele can impair testicular growth and fertility in a progressive, duration-dependent manner by interrupting the counter-current heat exchange of the pampiniform plexus, raising testicular temperature.
- Testicular growth — "catch-up" growth (normalisation of left relative to right testicular size) occurs in 32–83% of patients after repair; a significant left–right size discrepancy is the primary indication for correction.
- Fertility — reliable semen-quality standards by Tanner stage or age do not exist; trends toward poorer sperm quality may be limited to a subset, and neither varicocele grade nor postoperative catch-up growth reliably predicts ultimate semen quality.
- Hormonal function — LH and FSH levels are not consistently different with or without a varicocele in adolescents.
Diagnosis and Evaluation
Most varicoceles in children and adolescents are identified incidentally. About 85% are left-sided unilateral (asymmetric gonadal-vein anatomy); 15% are bilateral (more common) or right unilateral (less common).
- Physical exam — examine the patient supine and standing, with and without Valsalva; the veins should decompress when supine. Failure to decompress — particularly on the right — may reflect an abdominal or pelvic mass. Assess testicular consistency (the affected testis may be soft) and volume (which may drive surgical intervention).
- Imaging — abdominal/pelvic ultrasound or CT is considered for a new-onset or non-reducible varicocele, especially if large. Routine imaging based solely on the presence of a right varicocele is unnecessary.
Management
The two options are observation and varicocelectomy. Observation remains the approach of choice for most adolescents until a surgical indication appears.
Indications for Varicocelectomy
- Significant (≥20%) testicular size discrepancy
- Bilateral testicular hypotrophy
- Abnormal semen analysis (most reliable in boys at Tanner stage 5 and/or ≥18 years)
- Pain (a rare indication)
Benefits of Repair
Repair can halt the progressive, duration-dependent decline in semen quality — larger varicoceles improve more than small ones — and microsurgical varicocelectomy returns sperm to the ejaculate in up to 50% of azoospermic men with palpable varicoceles. A randomised controlled trial of surgery versus no surgery in infertile men found a 1-year pregnancy rate of 44% (surgery) vs 10% (control). Repair can also improve Leydig-cell function, raising serum testosterone in infertile men with low testosterone.
Anatomy
The pampiniform plexus drains via the gonadal/internal spermatic veins, which are ligated during repair. The deferential veins follow the vas deferens and drain into the internal iliac/hypogastric veins; they are spared, and as long as at least one set of deferential veins remains intact, venous return is adequate.
Surgical Approaches
| Approach | Recurrence | Hydrocele | Artery spared | Notes |
|---|---|---|---|---|
| Radiographic (embolisation) | High | — | n/a | Transfemoral, minimally invasive under local; maps collateral reflux. Downsides: recurrence, radiation, short follow-up |
| Retroperitoneal | High | High | No | Ligates the fewest (1–2) veins near the renal vein; still common in children |
| Laparoscopic | — | High | Varies | Essentially a retroperitoneal approach |
| Conventional inguinal | — | High | No | Exclude the ilioinguinal and genital branch of the genitofemoral nerve from the cord |
| Microsurgical inguinal / subinguinal | Low | Low | Yes | Artery- and lymphatic-sparing — the preferred technique. Subinguinal is the most popular and is preferred after prior inguinal surgery (though technically harder) |
| Scrotal | — | — | No | Avoided — high risk of arterial injury, testicular atrophy, and impaired spermatogenesis |
After a complete microsurgical varicocelectomy, only the testicular arteries, cremasteric arteries, lymphatics, and the vas with its vessels (deferential artery and vein) remain. An inguinal approach is chosen for a simultaneous ipsilateral hernia repair and gives access to the cremasteric/external spermatic and even gubernacular veins.
Adverse Events
- Recurrence (varicocele persistence) — highest with the retroperitoneal and radiographic approaches.
- Hydrocele — caused by lymphatic obstruction; highest with the retroperitoneal, laparoscopic, and conventional inguinal approaches.
- Testicular artery injury or ligation — risks testicular atrophy and impaired spermatogenesis.
Key Exam Points
- Varicocele = abnormal dilation and tortuosity of the gonadal/internal spermatic veins within the pampiniform plexus.
- Prevalence: ≈15% general population, 35% of men with primary infertility, 75-81% with secondary infertility.
- 85% are left unilateral due to asymmetric gonadal vein anatomy; 15% bilateral or right unilateral.
- Solitary right varicocele is rare — if abrupt onset, evaluate for retroperitoneal pathology (e.g., tumor).
- Nutcracker phenomenon: compression of left renal vein between aorta and SMA may contribute to varicocele in some boys.
- Grading: 0 (subclinical, US only), 1 (palpable with Valsalva), 2 (easily palpable), 3 (visible).
- Veins should decompress in supine position; failure to decompress (especially on the right) raises concern for an abdominal/pelvic mass.
- Routine imaging based solely on the presence of a right varicocele is unnecessary.
- Indications for varicocelectomy (4): ≥20% size discrepancy, bilateral testicular hypotrophy, abnormal semen analysis (most reliable at Tanner 5 or ≥18 years), and rarely pain.
- Significant L-R testicular size discrepancy is the primary indication for correction.
- "Catch-up" growth normalizes left vs. right testicular size in 32-83% after repair.
- RCT: pregnancy rate 44% at 1 year with surgery vs. 10% with no surgery in infertile men.
- Microsurgical varicocelectomy returns sperm to the ejaculate in up to 50% of azoospermic men with palpable varicoceles.
- Varicocelectomy can improve Leydig cell function and raise testosterone in infertile men with low T.
- Anatomy: pampiniform plexus drains via gonadal/internal spermatic veins (ligated); deferential veins follow the vas to internal iliac/hypogastric veins (spared) — at least one set of deferential veins preserves venous return.
- Microsurgical inguinal/subinguinal: artery- and lymphatic-sparing, low recurrence, low hydrocele — preferred technique. Subinguinal preferred after prior inguinal surgery.
- Retroperitoneal and radiographic approaches: high recurrence rates.
- Retroperitoneal, laparoscopic, and conventional inguinal: high hydrocele rates.
- Retroperitoneal and conventional inguinal: artery not preserved.
- Scrotal approach is avoided — risks testicular arterial injury, atrophy, and impaired spermatogenesis.
- Hydrocele after varicocelectomy is caused by lymphatic obstruction.
- Ilioinguinal and genital branches of the genitofemoral nerve must be carefully excluded from the cord during inguinal approach.