Are varicoceles painful?

Are Varicoceles Painful?

Yes, varicoceles can cause pain in approximately 2-10% of affected men, typically described as a dull, aching, or throbbing pain in the testicle, scrotum, or groin that worsens with prolonged standing and physical activity. 1

Clinical Presentation of Varicocele Pain

Varicoceles affect up to 15% of males and are the most common diagnosis in infertile men 2. When painful, the discomfort is characterized by:

• Pain quality: Typically described as a dull, aching, or throbbing pain; rarely acute, sharp, or stabbing 1
• Location: Testicle, scrotum, or groin area 1
• Timing: Often worse at the end of the day, especially after prolonged standing 2
• Relief factors: Usually improves when sitting or lying down with leg elevation 2

Mechanisms of Varicocele Pain

Several mechanisms may contribute to pain in varicoceles:

• Compression of surrounding neural fibers by dilated venous complex
• Elevated testicular temperature
• Increased venous pressure
• Tissue hypoxia
• Oxidative stress
• Hormonal imbalances
• Reflux of toxic metabolites from adrenal or renal origin 1

Diagnosis

Diagnosis of painful varicocele involves:

1. Physical examination: Palpation of the scrotum while the patient performs Valsalva maneuver
2. Grading system:
   • Grade I: Palpable only during Valsalva
   • Grade II: Palpable without Valsalva
   • Grade III: Visible through scrotal skin 3
3. Color Doppler ultrasound: Confirms diagnosis and assesses reflux 4

Management Algorithm

First-Line: Conservative Management

All patients with painful varicoceles should initially receive conservative treatment:

• Scrotal support/athletic supporter
• Non-steroidal anti-inflammatory drugs
• Limiting prolonged standing
• Avoiding heavy lifting
• Weight loss if obese 2, 1

Second-Line: Interventional Treatment

If conservative measures fail after 3-4 weeks, consider interventional options:

1. Surgical varicocelectomy:

   • Success rate: Approximately 80-88% for pain resolution 5, 4
   • Approaches: Microsurgical subinguinal (preferred), inguinal, or laparoscopic 3, 4

2. Endovascular therapy:

   • Gonadal vein embolization using coils or sclerosants
   • 87% complete pain relief at 39 months in one review 2

Predictors of Successful Pain Relief

Factors associated with better outcomes after varicocelectomy:

• Higher grade varicocele (Grade II-III)
• Characteristic dull, aching pain
• Duration of pain less than 6 months
• Previous failure of conservative management
• Use of microsurgical techniques 1

Important Caveats

1. Surgical success does not always translate to pain relief: Pain may persist even when no varicoceles are detected postoperatively 5

2. Rule out other causes: Consider other sources of scrotal pain such as epididymitis, orchitis, testicular torsion, or referred pain

3. Special consideration for right-sided varicoceles: Isolated right varicoceles are uncommon and may warrant evaluation for underlying abdominal pathology, although routine abdominal imaging is not recommended for all right-sided varicoceles 2

4. Nutcracker syndrome: Consider this diagnosis in patients with varicocele and hematuria, as compression of the left renal vein can lead to secondary varicocele formation 6