Dr. med. Dirk Manski

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Varicocele of the Testis (1/2)

Review literature: (Bong and Koo, 2004) (Miller et al, 2002) (Rubenstein et al, 2004).

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 the male adolescents and may cause pain, damage to the testes and infertility.

Classification of Varicoceles


Varicocele is common and in approximately 4–11% of adult males detectable by clinical examination. Approximately 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. The distal internal spermatic vein and pampiniform plexus become ectatic and decompensate. Collaterals develop to the internal and external iliac veins with disease progression.

Secondary Varicocele

Secondary varicoceles are caused by a retroperitoneal mass with compression of the internal spermatic vein. 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 leads to the increase of norepinephrine in the varicocele and – by diffusion – in the testicular artery. This leads to a vasoconstriction in the testes.

Increased Testicular Temperature

Increased venous reflux of warm blood from the core of the body increases the temperature of the testis.

Elevated Venous Pressure

Venous reflux leads to an elevated venous pressure leading to a temperature increase and impairment of the testicular blood supply.

Dysfunction of the Testis

A disturbed function of the germinal epithelium of the testis is the consequence of the above mentioned factors. Varicocele leads to microscopically visible impairment of Sertoli cell function, decreased inhibin secretion and thus an increase in FSH. The impaired blood supply impairs Leydig cell function, resulting in increased LH and sometimes decreased 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 a Varicocele

Diagnosis of a Varicocele

Scrotal Ultrasound with Doppler Examination

scrotal ultrasound of a varicocele with color Doppler

Scrotal ultrasound of a varicocele with color Doppler imaging: The left image shows ectatic veins in the spermatic cord. On the right: venous reflux with Valsalva maneuver.

Semen Analysis

A pathological semen analysis (oligozoospermia, asthenozoospermia, teratozoospermia) is possible. Even non-obstructive azoospermia can be caused by a varicocele. DNA fragmentation of spermatozoa is increased. Grading of the 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).

Laboratory tests:

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

Scrotal Thermography

Experimental investigation. Scrotal thermography is vague and unspecific.

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


Bong und Koo 2004 BONG, G. W. ; KOO, H. P.:
The adolescent varicocele: to treat or not to treat.
In: Urol Clin North Am
31 (2004), Nr. 3, S. 509–15, ix

Evers und Collins 2004 EVERS, J. L. ; COLLINS, J. A.:
Surgery or embolisation for varicocele in subfertile men.
In: Cochrane Database Syst Rev
(2004), Nr. 3, S. CD000479

Dubin, L. und R. D. Amelar (1970). Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. In: Fertil Steril 21, S. 606–609.

Die Varicocele testis im Kindes- und Jugendalter.
In: Urologe
41 (2002), S. 68–77

Rubenstein u.a. 2004 RUBENSTEIN, R. A. ; DOGRA, V. S. ; SEFTEL, A. D. ; RESNICK, M. I.:
Benign intrascrotal lesions.
In: J Urol
171 (2004), Nr. 5, S. 1765–72

  Deutsche Version: Varikozele: Ursachen und Folgen