Dilation of the pampiniform venous plexus; common cause of male subfertility.
Also known as: varicocele, scrotal varicosity, pampiniform plexus dilation
Overview
Abnormal dilation and tortuosity of the pampiniform venous plexus of the spermatic cord. Graded clinically (I-III) by Dubin classification.
Epidemiology
Present in ~15% of the general male population, ~35% of men with primary infertility, and ~80% of men with secondary infertility. Left-sided in 80-90%; bilateral in ~10-20%; isolated right-sided varicocele is uncommon and prompts evaluation for retroperitoneal mass.
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Question 1ReproductiveEasy
A 26-year-old man presents with a 6-month history of a dull, dragging ache in the left side of his scrotum that worsens after standing at work all day and resolves when he lies down. He and his partner have also been unable to conceive after 14 months of trying. On examination in the standing position, palpation of the left spermatic cord reveals a soft, tortuous mass that feels like a "bag of worms" and becomes more prominent with the Valsalva maneuver. The mass collapses when he lies supine, and it does not transilluminate. Which of the following is the most likely diagnosis?
ASpermatocele
BHydrocele
CTesticular tumor
DVaricocele
Reveal answer & full explanation
Correct answer: D — Varicocele
ASpermatocele
BHydrocele
CTesticular tumor
DVaricocele✓
Why Varicocele is correct
A varicocele is dilation and tortuosity of the pampiniform venous plexus caused by incompetent internal spermatic vein valves that permit retrograde venous flow.
The classic "bag of worms" cord mass that enlarges with standing and Valsalva and decompresses when supine is characteristic; left-sided predominance (80-90%) reflects the left gonadal vein draining at a right angle into the left renal vein.
It is the most common surgically correctable cause of male subfertility (found in ~35% of men with primary infertility), explaining this couple's difficulty conceiving through heat stress and oxidative damage to spermatogenesis.
Why the others are wrong
Hydrocele: a fluid collection within the tunica vaginalis that transilluminates and forms a smooth cystic mass surrounding the testis; it does not feel like a "bag of worms" and does not change with Valsalva or position.
Spermatocele: a cystic, transilluminating mass arising from the epididymis, separable from and superior/posterior to the testis; it is non-tender and does not vary with Valsalva.
Testicular tumor: a solid, firm, usually painless intratesticular mass that does not transilluminate or decompress; a soft, compressible cord mass that collapses when supine argues strongly against malignancy.
Question 2ReproductiveMedium
A 58-year-old man reports 2 months of a dull, dragging ache in the right scrotum. On examination in the standing position there is a soft, tortuous "bag of worms" mass along the right spermatic cord that does not decrease in size when he lies supine. He has also had a 5 kg unintentional weight loss and one episode of painless gross hematuria. Scrotal ultrasound confirms dilated right pampiniform veins greater than 3 mm with retrograde flow on Valsalva. Which of the following is the most appropriate next diagnostic test?
AUrine cytology for malignant cells
BContrast-enhanced abdominal CT scan
CSerum tumor markers AFP and beta-hCG
DRenal and bladder ultrasonography
Reveal answer & full explanation
Correct answer: B — Contrast-enhanced abdominal CT scan
AUrine cytology for malignant cells
BContrast-enhanced abdominal CT scan✓
CSerum tumor markers AFP and beta-hCG
DRenal and bladder ultrasonography
Why Contrast-enhanced abdominal CT scan is correct
An isolated right-sided varicocele, a new-onset adult varicocele, or one that fails to decompress when supine is a red flag for a retroperitoneal mass obstructing venous drainage.
This older man also has unintentional weight loss and painless gross hematuria, raising concern for renal cell carcinoma, which can invade the renal vein or IVC and present with a secondary varicocele.
Cross-sectional abdominal/retroperitoneal imaging (CT or MRI) is required to exclude a renal or retroperitoneal malignancy before any scrotal-directed management.
Why the others are wrong
Serum tumor markers AFP and beta-hCG — germ cell tumor markers are indicated when an intratesticular mass is seen, whereas this scrotal ultrasound shows only dilated pampiniform veins; normal markers would not exclude the retroperitoneal process suggested by his weight loss and hematuria.
Renal and bladder ultrasonography — ultrasound detects large renal masses but misses small tumors, retroperitoneal adenopathy, and venous tumor thrombus, so it is inadequate for gross hematuria with weight loss in a 58-year-old man.
Urine cytology for malignant cells — cytology has low sensitivity for renal and low-grade urothelial tumors and cannot image the retroperitoneum, so it is an adjunct to, not a substitute for, cross-sectional imaging.
Key concept
A right-sided or non-decompressing varicocele in an older patient, especially with weight loss or hematuria, mandates abdominal imaging; note that classic renal cell carcinoma produces a new-onset LEFT varicocele via left renal vein invasion.
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Anatomic: left gonadal vein drains at right angle into left renal vein (longer course, higher hydrostatic pressure, possible nutcracker phenomenon)
Tall, thin habitus; family history
Adolescence (most cases develop during puberty)
Pathophysiology
Incompetent valves in the internal spermatic veins allow retrograde flow, increasing pressure in the pampiniform plexus. Resulting heat stress, hypoxia, and oxidative damage impair spermatogenesis and Leydig cell function. The left-sided predominance reflects venous anatomy.
Clinical presentation
Symptoms
Often asymptomatic; incidental finding
Dull, dragging scrotal ache worse with standing, exertion, or prolonged sitting; relieved by lying down
Infertility (subfertility most common complaint that prompts evaluation)
Testicular asymmetry or atrophy (more often noticed by parent or clinician in adolescents)
Signs / physical exam
'Bag of worms' palpation in upright position with Valsalva, decompresses with supine position
Dubin Grade I (palpable only with Valsalva), Grade II (palpable without Valsalva), Grade III (visible through scrotal skin)
Ipsilateral testicular atrophy on exam or orchidometer
Right-sided or non-decompressing varicocele requires further evaluation for retroperitoneal pathology
Differential diagnosis
Hydrocele — Transilluminates; soft cystic mass surrounding testis; does not change with Valsalva
Spermatocele / epididymal cyst — Cystic mass in epididymis, separable from testis, transilluminates
Inguinal hernia — Mass extending into scrotum from inguinal canal, reducible, bowel sounds possible
Retroperitoneal mass causing secondary varicocele — New, right-sided, non-decompressing, or in older patient — obtain abdominal imaging to exclude renal cell carcinoma
Diagnostic workup
Diagnostic criteria
Clinical diagnosis with palpation in upright position; ultrasound confirms when needed.
Labs
Semen analysis if presenting with infertility (volume, concentration, motility, morphology)
FSH, LH, total testosterone if hypogonadal symptoms or abnormal semen analysis
Imaging
Scrotal ultrasound with color Doppler: dilated veins >2-3 mm with retrograde flow on Valsalva — used when exam equivocal or in obese patients
Abdominal/pelvic CT or MRI if right-sided or non-decompressing varicocele to evaluate for retroperitoneal mass (renal cell carcinoma classically presents as new-onset left varicocele due to renal vein invasion)
Diagnostic algorithm
Dubin Grade
Examination Finding
0 (subclinical)
Not palpable; only detected on ultrasound
I
Palpable only with Valsalva
II
Palpable without Valsalva
III
Visible through the scrotal skin
Dubin clinical grading of varicocele.
Treatment
First-line
Asymptomatic varicocele with normal semen analysis and no testicular atrophy: observation
Adolescents: monitor with serial testicular volumes; treat if significant size discrepancy (>20% smaller on the varicocele side), pain, or abnormal semen parameters in older adolescents
Symptomatic pain not relieved by supportive measures, OR clinical varicocele with abnormal semen analysis in an infertile couple, OR significant testicular atrophy: varicocelectomy
Isolated right-sided varicocele, new-onset adult varicocele, or one that does not decompress in supine position should prompt abdominal imaging to evaluate for retroperitoneal mass (renal cell carcinoma).
Microsurgical subinguinal varicocelectomy is the preferred operative approach due to lowest complication rates.
Varicocele repair improves semen parameters in most men and improves pregnancy rates in couples with clinical varicocele, abnormal semen analysis, and otherwise unexplained infertility (AUA/ASRM).
Adolescent management focuses on testicular volume preservation; significant ipsilateral testicular atrophy is an indication for intervention.
Subclinical varicoceles (only seen on ultrasound, not palpable) do not need repair.
References
AUA/ASRM 2014 — Report on Varicocele and Infertility: An AUA Best Practice Statement
AUA 2020 — AUA Guideline on the Diagnosis and Management of Infertility in the Male (Schlegel et al., J Urol 2021)
EAU Male Infertility — European Association of Urology Guidelines on Male Infertility (Salonia et al.)
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