Scrotal Pain: Five Signs You Have a Varicocele That Requires Treatment

If you are living with a dull ache or a dragging heaviness in the scrotum, there is a reasonable chance a varicocele is behind it. A varicocele is a varicose vein of the scrotum — the same failure of vein valves that produces the ropey veins people get in their legs, occurring in a location where it is considerably harder to ignore and considerably easier to avoid mentioning.

Varicoceles are common. They occur in roughly fifteen percent of men, far more often on the left side, and a great many of them never need to be treated at all. Like leg varicose veins, the presence of a varicocele is not by itself a reason to do anything about it. What matters is whether it is causing a problem.

What causes a varicocele

Almost anyone with testicles can develop one. The exact cause is not fully established, but varicoceles appear to stem from a faulty valve in the veins running through the tissue that suspends the testicle. When that valve stops closing properly, blood accumulates in the veins rather than draining upward, the veins dilate, and swelling and symptoms follow.

Anatomy, genetics and hormonal factors all appear to contribute. There is no known way to prevent a varicocele, and nothing you did caused it.

Five signs your varicocele needs treatment

Many varicoceles are completely asymptomatic, and an asymptomatic varicocele generally needs no treatment. If one or more of the following is true, though, treatment is worth discussing with a specialist:

• An aching, dragging pain in the scrotum, often worse with standing or at the end of the day
• Decreased testosterone levels
• Swelling in the scrotum
• Testicular atrophy — one testicle measurably smaller than the other (in adolescents, a difference of more than about 20%)
• Infertility with abnormal semen analysis results, when the varicocele can be felt on examination

Low testosterone is worth flagging separately, because men rarely connect it to the scrotum. Possible signs include erectile dysfunction, reduced libido, fatigue, low or anxious mood, and loss of muscle mass. If several of those have crept up on you and you also have a varicocele, the two may not be a coincidence.

The fertility connection is the most consequential. Although the mechanism is still not fully understood, varicoceles are believed to contribute to a substantial share of male-factor infertility cases — and they are one of the causes that can be treated, which may improve the chances of pregnancy.

How varicoceles are treated

The right treatment depends on how much trouble the varicocele is causing. For mild cases, that may mean nothing more than avoiding the clothing and activities that provoke discomfort, an over-the-counter anti-inflammatory, and a cold pack applied for fifteen minutes when the ache builds.

For a more significant varicocele, varicocele embolization is an effective, minimally invasive alternative to surgery. It is performed under local anesthesia with light sedation. A catheter is guided into the refluxing spermatic vein, and coils or a sclerosing agent are used to close that vein so blood reroutes through normal channels. There is no groin incision, no general anesthesia, and no risk of surgical injury to the artery or the vas deferens, although, as with surgery, a varicocele can occasionally recur.

Most men are back at desk work the following day, and full recovery generally takes about a week, with mild discomfort rather than the pain associated with open surgical repair. Scrotal ache improves for most men, though not for all. When the indication is fertility, semen parameters are typically reassessed at about three months, because sperm production runs on roughly a three-month cycle.

At our Midtown Manhattan practice, double board-certified vascular and interventional radiologist Dr. Yosef Golowa performs varicocele embolization routinely. If scrotal discomfort has become part of your normal, it is worth an hour to find out why.