Abdominal
Varicocele
What is a varicocele?
A varicocele is a widening of the small veins that drain blood away from the testicle, inside the scrotum.
It is often described as feeling like a “bag of worms” above the testicle.
Varicoceles are common — found in a significant minority of men — and most are found on the left side, because of the way the left testicular vein drains. Most varicoceles cause no problems at all and are noticed only incidentally, if at all.
What are the grades?
Doctors describe varicoceles by how they are found on examination:
- Grade 1: felt only when you strain or cough (bear down)
- Grade 2: felt easily when standing, without straining, but not visible
- Grade 3: visible through the skin as well as felt
Grade describes size, not danger. Even a large varicocele may need no treatment, and decisions are based on symptoms, testicle growth and fertility — not on the grade alone.
What symptoms can it cause?
- Often, none at all
- A dull, heavy ache in the scrotum, typically worse after standing for long periods, exercise or at the end of the day, and eased by lying down
- A visible or palpable tangle of veins, larger when standing and smaller after lying flat
- In teenagers, the affected testicle growing more slowly than the other side
Should I worry? A note on new varicoceles
A long-standing left-sided varicocele in a young man is almost always a simple, benign finding.
Two situations deserve a fuller check:
- A varicocele that appears suddenly, especially on the right side only, or in an older man
- A varicocele that does not shrink when you lie flat
These can occasionally be a sign of pressure on the vein inside the abdomen, so your doctor will usually arrange an abdominal scan in these cases. This is uncommon — it is simply the careful thing to do.
How is it assessed?
- Examination while standing, including a check of both testicles' size and consistency
- A scrotal ultrasound with Doppler, which confirms the veins' size and blood flow and measures the testicles precisely
- A semen analysis, if fertility is a concern — usually two samples, since results vary
- An abdominal ultrasound or scan, only in the “fuller check” situations above
Do all varicoceles need treatment?
No — most need none. Simple reassurance and observation are the right plan when:
- There is no pain, or only occasional mild discomfort controlled with supportive underwear and simple painkillers
- Both testicles are growing normally (in teenagers) or are of normal size
- Fertility is not an issue, or semen analysis is normal
Treatment is considered when there is a clear reason — listed next — rather than because a varicocele merely exists.
When is treatment advised?
- Persistent scrotal pain that is clearly from the varicocele and is not settling with simple measures
- In adolescents: the testicle on the affected side is falling behind in growth compared with the other side
- In men trying for a baby: a varicocele that can be felt on examination, together with an abnormal semen analysis, where the couple's infertility has no other explanation — treating the varicocele is one of the few correctable factors in male infertility
- Occasionally, a large varicocele that troubles a patient cosmetically, after full discussion
The treatment options
1. Observation
No procedure at all — with review if pain develops, growth changes (in teenagers), or fertility becomes a concern.
2. Embolisation
A radiologist blocks the vein from inside, threading a fine tube through a vein in the groin or neck and sealing the faulty vein with coils or a plug. No incision in the scrotum, done under local anaesthetic — but not every vein anatomy is suitable, and availability varies.
3. Surgery
The vein is tied off so blood re-routes through normal veins. Techniques include microscopic surgery low in the groin, and the laparoscopic (keyhole) approach described below.
In Dr. Elalfy's practice, varicocele repair is performed laparoscopically.
Laparoscopic varicocelectomy: the operation
- General anaesthesia, as a day case in most cases
- Two or three small incisions in the tummy; a camera (laparoscope) shows the testicular veins where they run inside the abdomen
- The dilated veins are clipped and divided high up (the laparoscopic Palomo approach), while the artery and the lymph channels are identified and protected as far as the anatomy allows
- Both sides can be treated in the same session when a varicocele is present on both sides — one of the practical advantages of the keyhole approach
- The operation usually takes about 30–45 minutes for one side
Recovery
- Home the same day in most cases; mild tummy and shoulder-tip discomfort for a day or two
- Desk work usually within a few days; gentle walking encouraged from day one
- Avoid heavy lifting, straining and vigorous exercise for about 2 weeks
- Scrotal support (snug underwear) helps comfort in the first days
- If fertility was the reason: a repeat semen analysis at about 3 months — a full cycle of sperm production takes roughly that long, so earlier testing is misleading
Possible complications and honest limitations
- Fluid collection around the testicle (hydrocele): the best-known drawback of tying the veins high, because lymph channels can be tied with them; it happens in a minority and sometimes needs a small operation of its own
- The varicocele coming back (recurrence) or never fully going — possible with every technique, embolisation included
- Bleeding, infection, and injury to the testicular artery — uncommon; artery injury can affect the testicle, which is why it is actively identified and preserved
- For fertility: semen quality improves in many men after repair, but improvement — and pregnancy — cannot be guaranteed. Repair corrects a factor; it does not promise an outcome
Common questions
Will treating it definitely help us have a baby?
No honest clinician can promise that. In men with a palpable varicocele and an abnormal semen analysis, repair improves the semen in a majority and improves the chance of pregnancy — which is why it is offered. It is one part of a couple's fertility picture, and your partner's assessment matters equally.
Does a varicocele lower testosterone or cause impotence?
A varicocele is not a usual cause of erection problems. There is ongoing research interest in varicocele and testosterone in selected older men, but low testosterone is not, by itself, a standard reason to operate — discuss your own hormone results with your doctor.
My teenage son has one. Should it be fixed now?
Not automatically. The deciding factor is testicular growth: if the affected testicle keeps pace with the other side on measurements, observation with periodic checks is standard. If it falls behind, repair is advised to protect its growth.
Go to the emergency room immediately, then call your surgeon
- Sudden, severe testicular pain — treat as an emergency always (a twisted testicle must be excluded within hours, and it is a different problem from varicocele)
- A rapidly swelling, painful scrotum after any procedure
- Fever above 38°C with scrotal redness or severe pain
A final word
A varicocele is common, usually harmless, and frequently needs nothing more than a name, an examination and reassurance.
When it does need treatment — for pain, for a teenager's testicle growth, or as part of a fertility plan — the laparoscopic repair is a short day-case operation with a quick recovery.
Bring your questions, and if fertility is the concern, bring your semen analysis results too — decisions are always better when they are made on measurements, not worries.
Full guide written by Dr. Tamer Elalfy