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Varicocele
A varicocele is dilatation of the pampiniform venous plexus, almost always on the left; it is treated when palpable with infertility and abnormal semen, in an adolescent with testicular growth lag, or for pain — and the preferred approach is microsurgical subinguinal repair.
Why it matters in the exam
A varicocele is present in about 15 percent of men and in 35 to 40 percent of men with primary infertility. About 90 percent are on the left, because the left testicular vein drains at a right angle into the left renal vein. An isolated right varicocele, one that appeared suddenly in an adult, or one that does not empty when lying down requires abdominal imaging to exclude a retroperitoneal mass — for example a renal tumour with renal vein thrombus. Grading: subclinical (ultrasound only), grade I (palpable only with Valsalva), grade II (palpable standing without Valsalva) and grade III (visible).
Indications for treatment: a palpable varicocele, an infertile couple and an abnormal semen analysis; an adolescent with a testicular volume difference above 20 percent (or above 2 mL), or with abnormal semen, or with pain. A subclinical varicocele is not treated. A man with a varicocele and a normal semen analysis — follow-up. For couples undergoing IVF anyway the benefit is limited, but repair sometimes improves semen quality.
Methods: microsurgical subinguinal repair — the lowest recurrence and hydrocele rates, because the artery and lymphatics are preserved; laparoscopic or retroperitoneal repair (Palomo) — in which the lymphatics are also ligated, so hydrocele is more common; and percutaneous embolisation — less invasive, with a slightly higher recurrence rate. The common complication of non-microsurgical operations is hydrocele. Improvement in semen analysis is usually seen after 3 to 6 months, which is about one cycle of sperm production.
Key points
- 90 percent on the left.
- Treatment: palpable with abnormal semen, adolescent with a small testis, pain.
- Microsurgical repair — least recurrence and hydrocele.
- Right or sudden — abdominal imaging.
- Subclinical — not treated.
Summary table
| Situation | Treatment | Note |
|---|---|---|
| Palpable with infertility and abnormal semen | Repair | Microsurgical subinguinal preferred |
| Adolescent with volume difference above 20 percent | Repair | Or abnormal semen or pain |
| Subclinical | No treatment | No proven benefit |
| Isolated right or sudden varicocele | Abdominal imaging | Exclude a mass or thrombus |
| Palomo or laparoscopic | High ligation | More hydrocele |
| Embolisation | Percutaneous approach | Slightly higher recurrence |
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Sources
- EAU Guidelines on Sexual and Reproductive Health, 2025 edition — Varicocele
- EAU Guidelines on Paediatric Urology, 2025 edition — Varicocele in children and adolescents
- AUA/ASRM Guideline: Diagnosis and Treatment of Infertility in Men, 2020 — Varicocele
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.