Varicocele: "The Bag of Worms"

A varicocele (from the Latin word, varix for dilated vein; and the Greek word, kele for tumor) is an enlargement of the veins in the scrotum and is similar to varicose veins that occur in the legs.  In younger men and boys, an abnormal appearing or feeling scrotum is often the reason for coming to a doctor.  In adult men, varicoceles most often present during an evaluation for infertility.  When a couple presents for infertility, a male factor is present in approximately 50% of couples (30% independent male factor infertility, 20% combined male and female factor infertility).  In this group, varicocele is related to semen abnormalities and is the #1 correctable male infertility factor.[1]

Etiologies of Male Infertility [1]

Varicoceles are present in:
- 10-15% of the general population
- 30-40% of men with primary infertility (couples never able to have children)
- 80% of men with secondary infertility (couples who have children, but are having difficulty conceiving now)

The anatomic defect in varicocele is an abnormal enlargement of the pampiniform venous plexus that drains the testicle in the scrotum.  The pampiniform plexus is a collection of veins that helps regulate the temperature of the testicle - as the testicle best makes sperm at temperature two degrees lower than body temperature.  The vast majority (99%) of varicoceles are left-sided and 30% of patients can have a varicocele on both sides.  Right-sided varicoceles are rare and can indicate a malignant process blocking the drainage on the right side of the abdomen.

Varicoceles are graded on a scale from I-III, based on physical examination findings and are often described as appearing "like a bag of worms" in the scrotum.  A Valsalva maneuver is performed by forcefully exhaling against a closed airway (like bearing down to have bowel movement), and helps to distinguish the grades of varicocele.

Grade III Varicocele

Grade I:  Present by palpation only with Valsalva
Grade II: Present by palpation without Valsalva
Grade III: Visible on exam

The work-up for a varicocele usually only involves a semen analysis, fertility labs when applicable, and does not generally involve imaging studies.  Occasionally small, non-palpable varicoceles can be found on scrotal ultrasounds done for other reasons.  These non-palpable varicoceles are not associated with infertility.

There are a number of mechanisms by which varicoceles can cause decreased spermatogenesis (or the creation of sperm).  These mechanisms involve loss of the "heat sink" to the testicle which can cause:

• damage by direct hyperthermic injury to sensitive sperm progenitors via DNA damage or reactive oxygen species (ROS)
• testicular atrophy
• inadvertent delivery of adrenal metabolites to the testicles

There are therefore three scenarios where correction of a varicocele are routinely recommended: [2,3]

1. Adult Man with a palpable or visible varicocele 
• abnormal semen parameters 
• in a couple with known infertility
• normal, corrected or optimized female factor infertility
2. Adult Man with a palpable or visible varicocele 
• abnormal semen parameters 
• not in a relationship but desiring fertility preservation
3. Adolescent Man with a palpable or visible varicocele
• 10-20% reduction of testicular size (i.e. volume) on the same side
• Pain - often dull or throbbing, worse with standing

The options for treatment and outcomes for men undergoing repair of their varicocele will be reviewed in later entries of this blog.  To read more about varicocele and repair options check the Brady Website.

This blog entry was written by Jason Michaud, MD, PhD, Junior Assistant Resident (URO-2) at the Brady Urological Institute at Johns Hopkins.









[1] Sigman M, Lipshultz L.l., Howards S.S. Infertility in the Male, 4th Ed. Chapter 10.
[2] Sharlip I, Jarow J. Report on Varicocele and Infertility. AUA Best Practice Policy and ASRM Practice Committee Report. April 2001.
[3] Guidelines for the investigation and treatment of male inferltility. Eur Urol 2012. Jan;61(1):159-63