A scrotal varicocele is a widening of the veins along the cord that holds up a man's testicles (spermatic cord or vein). Varicoceles are very common, occurring in 19-26% of adolescents, and about 10% of all males. They occur on the left side 90% of the time, but may also be bilateral (occuring on both sides). Varicoceles are generally not diagnosed before puberty.

Patients can be seen by Texas Children's experts in Urology.

Causes & Risk Factors

Doctors believe varicocele is related to the angle with which the spermatic vein joins the kidney vein on the left side causing increased pressure in the vein and problems with the  valves in the testicular vein.   Varicoceles are more common in tall, thin males. 

Symptoms & Types

Varicoceles are generally painless. Classically, they are described as feeling like a “bag of worms” in the scrotum. They are more prominent when the patient is standing or straining. There are three grades of varicocele:

  • Grade I: able to be felt only when the patient is straining (valsalva maneuver)
  • Grade II: able to be felt at rest, but not visible
  • Grade III: clearly visible on exam

Varicocele can increase risk of impaired testicular growth, impaired sperm production, decreased fertility, and possibly decreased hormone production. The cause of these is not clearly understood, but thought to be related to increased temperature due to increased blood flow in the area.

Diagnosis & Tests

Diagnosis is made by a physical exam. The exam is typically performed in the laying and standing; the scrotum is observed for visible swelling and examined while the patient is at rest and during straining.

When a varicocele is found, the testicles must be assessed for size symmetry and shrinkage. This can be done on exam with use of an orchidometer (plastic cut-outs in various sizes) or with a scrotal ultrasound to obtain more accurate measurement.   If there is a greater than 20% difference in size between the testicles (testicle on side with varicocele is smaller), repair is indicated. Scrotal ultrasound can also demonstrate subclinical (grade 0) varicoceles.

A semen analysis may be done in adults, but is not performed in children and adolescents.

Treatment & Care

Adolescents with varicoceles that do not cause discomfort and with no significant testicular size difference may be observed with yearly scrotal ultrasounds or physical exams by a urologist.

Varicoceles should be considered for surgical correction if they are painful or associated with a smaller left testicle.  The dilated veins are tied off and cut. Surgical techniques vary and include different well accepted approaches.

Living & Managing

After a varicocele repair, some patients may form fluid around the testicle (a hydrocele ); this may develop years after varicocele repair and can resolve spontaneously or require further intervention.