PassFinals
Renal & Urology

Varicocoele

A varicocoele is dilated pampiniform venous plexus, usually left-sided and benign; treatment is not automatic and is considered mainly for selected fertility, pain or adolescent testicular-development indications.

In a nutshell

A varicocoele is a usually left-sided bag-of-worms venous swelling that becomes more prominent standing or with Valsalva and decompresses supine. Observe typical minimally symptomatic disease. Current NICE supports considering treatment when a clinically detected varicocoele occurs in a couple trying to conceive spontaneously with reduced semen parameters, taking female factors into account. Refer atypical right-sided/sudden/non-decompressing lesions, significant pain or adolescent testicular-development concerns.

Classic presentation

A young man has a left-sided bag-of-worms swelling that reduces when supine; it may be incidental or associated with a dull ache, testicular asymmetry or subfertility.

Key points

  • Examine standing and supine; a typical varicocoele is more prominent standing and decompresses when lying down.
  • Most are left-sided and benign, but sudden, right-sided, bilateral or non-decompressing lesions are atypical.
  • Do not treat an incidental or ultrasound-only varicocoele automatically.
  • Current NICE fertility indication: clinically detected varicocoele + trying to conceive spontaneously + reduced semen parameters, with female fertility factors considered.
  • Urology/paediatric urology input is appropriate for significant pain, progressive testicular asymmetry/growth concern or an uncertain diagnosis.

First-line investigation

Standing and supine examination with testicular-volume assessment; semen analysis when fertility is a current goal and ultrasound when examination is uncertain.

Management

Recognise atypical or acute disease

  • Acute pain requires torsion assessment; sudden, right-sided, bilateral or non-decompressing varicocoele requires prompt specialist review and consideration of abdominal/renal imaging.5,1

Confirm the clinical context

  • Examine standing and supine; use Doppler ultrasound for diagnostic uncertainty or testicular-volume assessment, and semen analysis when trying to conceive.1,4,2

Treat selected patients

  • Consider radiological or surgical treatment for a clinically detected varicocoele with reduced semen parameters in a couple trying to conceive spontaneously; discuss female fertility factors and preferences.4

Monitor symptoms and testicular development

  • Refer persistent pain, progressive testicular asymmetry/growth concern or recurrence after treatment to urology/paediatric urology.3,2

Exam traps

  • A varicocoele is usually left-sided, but right-sided or non-decompressing disease is not automatically benign.
  • Do not treat every varicocoele found on ultrasound.
  • Use the current NICE fertility criteria rather than saying all varicocoeles in subfertility require repair.
  • Do not label a painful acute scrotum as varicocoele without excluding torsion.
  • A varicocoele is venous and does not transilluminate like a hydrocoele or epididymal cyst.

Illustrations

Bag of worms on examinationA clinical photograph of a large left-sided varicocoele with visibly dilated, tortuous veins producing the characteristic bag-of-worms appearance.Pit2802, Wikimedia Commons · CC-BY-SA-4.0
Colour Doppler of pampiniform refluxA colour Doppler ultrasound showing dilated pampiniform veins with venous reflux on Valsalva.Chee-Wai Mak and Wen-Sheng Tzeng, Wikimedia Commons · CC-BY-3.0

Key sources

  1. NICE CKS, Scrotal pain and swelling: assessment (UK clinician reference for assessment of scrotal pain and swelling and atypical scrotal swellings; access may require an NHS or professional account)
  2. BAUS, Testicular lump (BAUS overview of examination, ultrasound, benign scrotal swellings and treatment options; page dated March 2024)
  3. BAUS, Microsurgical varicocele ligation (BAUS procedure information for surgical treatment of varicocoele and related risks; use with specialist discussion of embolisation or other approaches)
  4. NICE NG257, Fertility problems: assessment and treatment (Current recommendation 1.28.1: consider radiological or surgical treatment for clinically detected varicocoele with reduced semen parameters in a couple trying to conceive spontaneously, taking female fertility factors into account; published 31 March 2026)Published 31 Mar 2026
  5. BAUS, Acute scrotal pain (BAUS trainee guidance on testicular torsion and the acute scrotum, including atypical varicocoele assessment)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.