GPAtlas🧭 When to suspect
A varicocele is an abnormal dilatation and tortuosity of the pampiniform venous plexus within the spermatic cord – in effect, a varicose vein of the scrotum.
• A varicocele arises when the valves in the internal spermatic (testicular) vein become incompetent, allowing blood to reflux and pool.
• Around 80–90% occur on the left, because the left testicular vein drains into the left renal vein at a sharp right angle.
• The left vein also has a longer, higher-pressure course than the right, which drains directly into the inferior vena cava.
Most varicoceles are asymptomatic and found incidentally. When symptoms occur, the classic story is:
• A scrotal swelling that feels like a "bag of worms".
• A dull ache or dragging heaviness that is worse on standing or with exercise and eases on lying down.
The two clinical skills that matter in primary care:
• To recognise the benign primary varicocele that needs only reassurance.
• To spot the small minority that signal something more serious – a new, right-sided, or non-reducing varicocele.
| Clinical grade | How it is detected on examination |
|---|---|
| Subclinical | • Neither visible nor palpable • Identified only on Doppler ultrasound (often an incidental finding) • No treatment indicated |
| Grade 1 (small) | Palpable only during Valsalva (cough or strain). |
| Grade 2 (moderate) | Palpable at rest without Valsalva, but not visible through the skin. |
| Grade 3 (large) | Visible through the scrotal skin at rest – the overt "bag of worms". |
Suspect a varicocele in an adolescent or adult man presenting with the above.
Consider it as a contributing factor in any couple presenting with difficulty conceiving:
• Varicoceles are found in roughly 15% of all men.
• In men with abnormal semen parameters, they are found in up to 35–40%.
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