Understanding Varicocele: Symptoms, Causes, and Treatment in the UK

A varicocele is a condition where the veins inside the scrotum—the loose bag of skin that holds the testicles—become enlarged or dilated. These veins are known as the pampiniform plexus. Functionally, these veins are responsible for draining deoxygenated blood from the testicles. When the valves within these veins fail to work correctly, blood pools, causing the veins to swell.

This condition is remarkably similar to varicose veins found in the legs. In the UK, varicoceles are relatively common, particularly in young men aged 15 to 25. While they typically develop on the left side due to the anatomical structure of the male reproductive system, they can occasionally occur on both sides.

Many men with a varicocele may never experience noticeable symptoms and might only discover the condition during a routine physical examination or a fertility investigation. However, when symptoms do occur, they often include:

• Scrotal Swelling: A visible or palpable mass in the scrotum, frequently described as feeling like a 'bag of worms'.
• Dull Ache: A recurring, heavy, or dull ache in the scrotum, which often worsens during physical exertion or after standing for long periods.
• Size Discrepancy: The affected testicle may appear smaller than the other (testicular atrophy).
• Relief when Lying Down: Discomfort typically eases when lying flat on your back, as gravity helps blood drain from the pooled veins.

The severity of a varicocele is often graded from I to III, with Grade I being the smallest (only detectable during a physical manoeuvre) and Grade III being the largest and most visible.

The precise cause of varicoceles is not always clear, but the prevailing medical consensus focuses on the failure of valves within the spermatic cord. These valves are intended to keep blood flowing in one direction—back towards the heart. When they malfunction, the resulting backflow causes the veins to dilate.

The reason why the left side is more frequently affected relates to the angle at which the left testicular vein enters the left renal vein. This creates higher pressure on the left side compared to the right. While there are no specific lifestyle risk factors that cause a varicocele to develop, they usually appear during puberty when blood flow to the testicles increases significantly.

One of the primary reasons men seek medical advice for a varicocele is its potential impact on fertility. Research suggests that varicoceles are present in approximately 35% to 40% of men experiencing primary infertility issues.

The leading theory regarding this link involves temperature regulation. The scrotum is designed to keep the testicles slightly cooler than the rest of the body to ensure optimal sperm production. The pooling of blood in a varicocele can raise the temperature of the testicles, which may decrease sperm count, reduce sperm motility (the ability of sperm to swim), and increase the number of abnormally shaped sperm. However, it is important to note that many men with varicoceles go on to father children without any medical intervention.

If you suspect you have a varicocele, the British clinical pathway usually begins with a physical examination by a GP. The doctor will likely examine you while you are standing and while you are lying down. They may ask you to take a deep breath and hold it while bearing down (the Valsalva manoeuvre) to make the veins more prominent.

If the diagnosis is not clear from a physical exam, or if the doctor wants to rule out other scrotal conditions, a scrotal ultrasound may be arranged. This is a painless procedure that uses sound waves to create an image of the veins and measure blood flow. In the UK, this is the standard diagnostic tool used by both the NHS and private specialists.

Treatment is not always necessary. If a varicocele is not causing pain or affecting fertility, your clinician may simply recommend 'watchful waiting'. However, if treatment is required, there are two main approaches in the UK:

• Varicocelectomy (Surgery): This is usually performed as day-case surgery under general or local anaesthetic. The surgeon identifies the affected veins and ties them off to redirect blood flow into healthy veins. Microsurgical subinguinal varicocelectomy is often considered the 'gold standard' as it has the lowest recurrence rate.
• Radiological Embolisation: This is a less invasive non-surgical procedure. A radiologist inserts a thin tube (catheter) into a vein in the groin or neck. Using X-ray guidance, they place a tiny coil or special liquid into the varicocele to block the blood flow, causing it to shrink. Recovery time is typically shorter than with surgery.

If you notice any new lumps, bumps, or changes in the appearance of your scrotum, it is essential to seek a professional medical opinion. While a varicocele is benign, it is important to distinguish it from other conditions that require urgent attention, such as testicular torsion or testicular cancer.

You should consult an online GP if:

• You have a dull ache or heaviness in your scrotum that interferes with your daily activities.
• You have noticed a direct correlation between standing for long periods and scrotal pain.
• You and your partner have been trying to conceive for over a year without success.
• The scrotum appears visually different or you feel a 'bag of worms' mass.

A GP can provide an initial assessment, discuss your symptoms in a confidential environment, and advise whether a referral to a urologist for further imaging or treatment is necessary.