Varicocele: Symptoms, Fertility Concerns, and UK Treatment Options

A varicocele is a common condition where the veins in the scrotum—the pampiniform plexus—become enlarged. These veins are responsible for draining oxygen-depleted blood from the testicle. When the valves within these veins fail to function correctly, blood pools, causing the veins to swell and dilate. This process is very similar to how varicose veins develop in the legs.

According to NHS data, varicoceles affect approximately 15% of the male population. They most commonly develop during puberty and are frequently found on the left side of the scrotum due to the anatomical positioning of the male reproductive system. While they are often asymptomatic, they are a significant factor in male factor infertility, present in about 40% of men attending fertility clinics.

For many men in the UK, a varicocele causes no obvious symptoms and is only discovered during a routine physical check-up or a fertility assessment. However, when symptoms do occur, they typically include:

• A 'bag of worms' sensation: The most distinct sign is a cluster of thickened, twisted veins that can be felt through the skin of the scrotum.
• Scrotal swelling: You may notice a lump or visible enlargement, usually on the left side.
• Dull ache or heaviness: A recurring discomfort in the scrotum that often worsens throughout the day or after physical exertion.
• Testicular atrophy: The affected testicle may appear smaller than the other due to the blood pooling and increased temperature.

Discomfort is often relieved by lying on your back, as this helps the blood to drain away from the scrotum naturally.

One of the primary reasons men seek medical advice for a varicocele is its potential impact on male fertility. The testicles are located outside the body cavity because they require a temperature slightly lower than the rest of the body for optimal sperm production. The pooling of blood in a varicocele can raise the temperature within the scrotum.

This increased heat can lead to:

• Decreased sperm count (oligospermia).
• Reduced sperm motility (how well sperm move).
• Changes in sperm morphology (shape).

NICE guidance suggests that while not every man with a varicocele will be infertile, it is a leading cause of secondary infertility (the inability to conceive after previously having done so). If you and your partner have been trying to conceive for over a year without success, a varicocele check is a standard part of the UK diagnostic pathway.

If you suspect you have a varicocele, the first step is a physical examination. A GP will typically examine you while you are standing and while you are lying down. They may ask you to take a deep breath and bear down (a technique known as the Valsalva manoeuvre), which increases pressure and makes the enlarged veins easier to detect.

If the diagnosis is not clear from a physical exam, or if the GP needs to rule out other causes of scrotal lumps (such as a hydrocele or spermatocele), they may refer you for a scrotal ultrasound. This is a painless, non-invasive scan that uses sound waves to create an image of the veins and blood flow within the scrotum.

Not all varicoceles require treatment. In the UK, the NHS generally recommends intervention only if the varicocele is causing significant pain, if there is clear evidence of testicular atrophy, or if infertility is a confirmed issue. The two main procedures are:

1. Varicocele Surgery (Varicocelectomy)

This is usually performed as a day-case procedure under general or local anaesthetic. The surgeon identifies the affected veins and ties them off or clips them to redirect blood flow into healthy veins.

2. Varicocele Embolisation

A less invasive alternative performed by a radiologist. A small catheter is inserted into a vein (usually in the groin or neck). Using X-ray guidance, the doctor places a small coil or fluid into the varicocele to block it off. This procedure has a shorter recovery time compared to traditional surgery.

If you have noticed a new lump, a change in the shape of your scrotum, or a persistent dull ache, it is important to seek medical advice. You can speak to a GP online to discuss your symptoms from the comfort of your home. This is particularly useful if you are feeling embarrassed or unsure if your symptoms require an in-person referral.

An online consultation allows you to describe the duration of your symptoms, any impact on your daily life, and any concerns regarding fertility. The doctor can then advise whether you need a physical examination, provide a sick note if recovery from a procedure is required, or guide you toward the appropriate UK specialist (Urologist) for further investigation.

While surgery is the only way to physically remove a varicocele, mild symptoms can often be managed with simple lifestyle adjustments. NHS guidance suggests:

• Supportive underwear: Wearing snug-fitting briefs or a jockstrap instead of loose boxers can provide support and relieve the feeling of heaviness.
• Pain relief: Over-the-counter options like paracetamol or ibuprofen can help manage occasional dull aches.
• Avoiding heavy lifting: Reducing activities that increase abdominal pressure may prevent the veins from becoming further engorged.