Does Varicocele Cause Pain? Symptoms, Causes & When It Happens

What is a varicocele?

A varicocele is an abnormal enlargement and dilation of the veins within the scrotum that drain blood from the testicles. While it is usually painless, some patients may experience a dull, aching discomfort, especially after prolonged standing or physical activity. Varicoceles are the most common cause of abnormal semen parameters, such as low sperm motility, low sperm count, and irregular morphology. They may also affect testicular growth over time.

Varicoceles affect nearly 15 to 20% of males and up to 40% of infertile males. While many men are asymptomatic, some may notice mild to moderate discomfort that is often ignored until fertility issues appear.

What are the Symptoms of Varicocele?

Varicocele often has no obvious symptoms. Some individuals may experience mild discomfort, swelling or a feeling of heaviness in the scrotum. Varicoceles most commonly occur on the left side due to anatomical factors.

The possible symptoms of varicocele include the following:

Pain:

A dull, aching pain that may worsen after long periods of standing or toward the end of the day. Lying down often eases the pain.

A mass in the scrotum:

A larger varicocele may appear like a “bag of worms” above the testicle. On the other hand, a smaller varicocele may not be visible but can be felt on examination.

Infertility:

Varicoceles can make it difficult to conceive a child. However, not all varicoceles affect fertility.

Differently sized testicles:

The affected testicle might be visibly smaller than the other testicle.

What causes a Varicocele?

A varicocele is caused by the enlargement of veins within the scrotum due to impaired blood flow. This generally occurs when the valves inside the veins that normally regulate blood flow do not function properly. It results in blood pooling in the veins, causing them to dilate.

Most commonly, varicoceles occur on the left side. It is because the left testicular vein drains into the left renal (kidney) vein, which has higher pressure compared to the right side, and follows a longer pathway. Due to these factors, blood flow becomes less efficient and the likelihood of vein enlargement increases.

Other contributing factors may include congenital weakness in the vein walls or faulty venous valves, similar to those occurring in varicose veins in the legs.

In rare cases, a mass or tumour in the abdomen or pelvis may compress the veins and disrupt normal blood flow, which can lead to the development of a varicocele.

How does a varicocele affect the testicles and fertility?

The primary concern with a varicocele is its effect on fertility, even though many males with varicoceles can still father children. In others, sperm may be affected in terms of movement, shape, count, and overall function. Does a varicocele cause pain? While pain is uncommon, internal testicular changes may at times cause discomfort.

Several mechanisms have been proposed to explain how varicoceles affect sperm and testicular function. One of the most well-known theories is that the temperature inside the testicles increases due to blood pooling, which negatively affects sperm production. Also, pooled blood may increase oxidative stress, reduce oxygen supply (hypoxia), and lead to the accumulation of harmful toxins.

Apart from that, increased pressure within the veins can damage testicular tissue. In a few cases, substances from the kidneys or adrenal glands can flow backward into the testicular vein, further affecting sperm quality.

Varicoceles are also associated with sperm DNA damage (fragmentation), which may decrease sperm motility and efficacy and affect normal structure. Even if varicoceles generally do not present symptoms, around 2% to 10% of males may experience pain. When present, it is referred to as a dull, aching, or throbbing sensation because of increased temperature, oxidative stress, venous pressure, or expansion of nerve fibers in the spermatic cord.

If left untreated, larger varicoceles can result in testicular shrinkage (atrophy), decreased testosterone levels, and lower sperm production (oligospermia). Lower testosterone levels are more common in older males. Yet, surgical treatment (varicocelectomy) helps improve testosterone levels in more than 80% of men and significantly in males with already low testosterone levels.

How to evaluate a varicocele?

Diagnosis of a varicocele typically begins with a physical evaluation. A high-resolution colour Doppler ultrasound is commonly used to confirm the diagnosis. This imaging technique can detect dilated scrotal veins (usually measuring 3 mm or more in diameter) and assess abnormal blood flow.

Thermal imaging is another painless, non-invasive, non-contact procedure for assessing and confirming a possible varicocele. Testicular strain elastography helps identify patients with varicocele who might benefit from treatment.

Historically, doctors considered the prospect of a renal tumour extending into the vena cava as a possible reason behind any isolated right-sided varicocele. A right-sided renal vein tumour may extend into the vena cava, resulting in a venous blockage. It may cause blockage of the spermatic vein and a right-sided varicocele. Doctors may also consider computed tomography (CT) if the above measures don't work.

How to treat a varicocele?

Not all varicoceles require treatment. Management is usually recommended if the individual experiences pain, infertility, or testicular atrophy (especially in adolescents). If the patient needs treatment, the goal should be to remove or tie off the veins that supply blood to the spermatic cord. Here are some good options:

Varicocelectomy

This is the most common treatment. In this procedure, doctors make a 1-inch incision in the scrotum. They use a magnifying glass or a microscope to view the small veins. While this procedure can be performed under local or general anaesthesia, it has high success rates with low complication risk.

Laparoscopic surgery

This is a minimally invasive approach in which small incisions are made to insert a camera and surgical instruments. The affected veins are identified and sealed. This procedure is performed under general anesthesia and may be used in selected cases.

These procedures are generally effective. However, complications such as recurrence, fluid accumulation around the testicle (hydrocele), or, rarely, injury to surrounding structures may happen.

Varicocele treatment without surgery

Conservative measures can help with mild symptoms. Pain relief with medications such as Ibuprofen or Acetaminophen, wearing supportive underwear and avoiding prolonged standing are generally helpful.

What Does Recovery from Varicocele Look Like?

Healthcare providers perform varicocele surgery typically on an outpatient basis. It means the patient doesn't need to stay in the hospital for long. Recovery is generally quick and the patients can return to their normal routines within 1 to 2 weeks, based on the type of procedure performed.

However, there are some possible side effects that the patient must be aware of before undergoing this procedure.

Mild pain or swelling in the treated area is common during the initial recovery period. It typically resolves within a few days. Patients must avoid heavy lifting, strenuous exercise, and sexual activity for a short period to allow proper healing.

In terms of fertility, varicocele treatment is mainly aimed at improving sperm quality over time. However, results may take several months to become noticeable.

There are some potential risks, like recurrence (in about 5% of cases), fluid accumulation around the testicle (hydrocele), or infection. These are relatively uncommon. When symptoms persist or worsen after treatment, the doctor may consider further evaluation or additional procedures.

What Complications Can Varicocele Cause?

Many varicoceles do not lead to serious problems. However, larger or untreated cases can result in complications, which particularly affect fertility and testicular function:

• Azoospermia: Varicoceles can affect sperm count, motility, and structure. This may lead to difficulty conceiving. In severe cases, it may progress to azoospermia, a condition in which no sperm are present in the semen.
• Low testosterone levels: Varicoceles can also reduce testosterone production. It is the hormone responsible for maintaining libido, muscle mass, energy levels and overall male reproductive health.

Conclusion

In a varicocele, the veins within the scrotum become enlarged. It is similar to varicose veins in the legs. While it is often asymptomatic, some individuals may experience a dull, aching discomfort or a feeling of heaviness, especially after prolonged standing. Varicoceles most commonly occur on the left side because of anatomical factors.

Varicoceles may impair testicular function in some cases by increasing temperature, reducing oxygen supply, and promoting oxidative stress. This may negatively affect sperm quality. While many varicoceles are harmless, larger or untreated cases can cause complications such as infertility, reduced testosterone levels, or testicular atrophy.

Early medical evaluation is important for varicoceles, especially when symptoms such as pain, swelling, or fertility concerns arise. Timely diagnosis and appropriate management can help prevent complications and improve overall reproductive health outcomes.