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. It 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 and 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", or 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 are to recognise the benign primary varicocele that needs only reassurance, and 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, and consider it as a contributing factor in any couple presenting with difficulty conceiving – varicoceles are found in roughly 15% of all men but in up to 35–40% of men with abnormal semen parameters.
Source: NICE · BAUS
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