Dr. med. Dirk Manski

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Varicocele: Causes, Symptoms, and Diagnosis

Varicocele: Definition and Classification

A varicocele is defined as ectatic and tortuous veins of the pampiniform plexus of the spermatic cord. Varicoceles are found in 15% of male adolescents and may cause pain, damage to the testes, and infertility. Guidelines: EAU Guideline Paediatric Urology, EAU Guideline Sexual and Reproductive Health AUA Guideline: Infertility in Men.

Classification of Varicoceles


Varicocele is common; approximately 4–11% of adult males have a varicocele by clinical examination. Over 90% of primary varicoceles are on the left side; right-sided varicoceles are usually less severe and only detectable by Doppler ultrasound imaging. A high BMI decreases the likelihood of varicocele (Rais et al., 2013). The prevalence is up to 30% when Doppler sonography is used for varicocele diagnosis (ChancWalters et al., 2012). The clinical prevalence of varicocele in men with subfertility is 25% (Marmar et al., 2007).

Etiology of Varicocele

Primary Varicoceles

The nearly perpendicular configuration of the renal vein with the left internal spermatic vein combined with incompetent venous valves leads to a long blood column with high pressure in an upright position. The distal internal spermatic vein and pampiniform plexus become ectatic and decompensate. Collaterals develop in the internal and external iliac veins with disease progression.

Secondary Varicocele

A retroperitoneal mass with compression of the internal spermatic vein causes secondary varicoceles. Another cause of secondary varicocele is the Nutcracker syndrome: compression of the left renal vein between the superior mesenteric artery and the aorta.

Pathophysiology of Testicular Dysfunction

Reflux of (Adrenal) Blood

Reflux of adrenal blood increases norepinephrine in the testicular vein and – by diffusion – in the testicular artery, leading to vasoconstriction in the testes. Venous reflux also causes oxidative stress by additional metabolites.

Increased Testicular Temperature

Venous reflux of warm blood from the body's core increases the testicular temperature.

Elevated Venous Pressure

The increased venous pressure impairs the testicular blood flow.

Dysfunction of the Testis

A disturbed function of the germinal epithelium of the testis is the consequence of the factors mentioned above. Varicocele leads to microscopically visible impairment of Sertoli cell function, decreased inhibin secretion, and increased FSH. The impaired blood supply impairs Leydig cell function, resulting in increased LH and sometimes subnormal testosterone concentrations. Markers of subfertility are pathological parameters in the semen analysis (OAT syndrome) and increased DNA fragmentation of the spermatozoa.

Testicular Pathology due to varicocele

Gross Pathology:

Higher grade varicoceles lead to an atrophy of the testis.

Microscopic Pathology:

Signs and Symptoms of Varicocele

Diagnosis and Imaging of Varicocele

Ultrasound Imaging with Doppler

Signs of varicocele are ectatic veins in the spermatic cord (venous diameter of more than 3.5 mm) and a reduced testicular size (difference >20% or 2 ml). It is essential to exclude testicular or retroperitoneal tumors.

figure Ultrasound imaging of the spermatic cord with varicocele testis
Ultrasound imaging of the spermatic cord: the left image shows ectatic veins. On the right, there is venous reflux due to a Valsalva maneuver.

figure Testicular ultrasound imaging of a left-sided intratesticular varicocele with testicular atrophy
Testicular ultrasound imaging of a left-sided intratesticular varicocele with testicular atrophy. The left image shows intratesticular ectatic veins, the right image shows venous reflux with Valsalva maneuver.

Semen Analysis

Pathological findings in semen analysis (oligozoospermia, asthenozoospermia, teratozoospermia) and DNA fragmentation of spermatozoa are possible. The grading of varicocele correlates with markers of subfertility: for example, up to 55% of men with grade III varicocele have a pathological semen analysis (Damsgaard et al., 2016). Even non-obstructive azoospermia can be caused by a high-grade varicocele.

Laboratory tests:

An elevated FSH and low testosterone are typical for a testicular dysfunction due to a high-grade varicocele.

Scrotal Thermography

Scrotal thermography is an experimental, vague, and unspecific investigation.

Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z


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  Deutsche Version: Varikozele: Ursachen und Folgen