Is a 6mm varicocele excessive and can it cause erectile dysfunction (ED) and low libido?

Varicocele Size, Erectile Dysfunction, and Libido

A 6mm varicocele is not considered excessive and is unlikely to directly cause erectile dysfunction or low libido, as varicoceles primarily affect fertility parameters rather than sexual function. 1, 2

Understanding Varicoceles and Their Classification

• Varicoceles are abnormal dilations of the pampiniform plexus of veins in the scrotum, affecting approximately 15% of the general male population but present in 35-40% of men with infertility 2
• Varicoceles are typically graded clinically on physical examination:
  • Grade 1: Palpable only during Valsalva maneuver
  • Grade 2: Palpable without Valsalva
  • Grade 3: Visible through the scrotal skin 3
• Ultrasound measurements (like 6mm) are not the standard clinical grading system for varicoceles, and routine use of ultrasonography to identify non-palpable varicoceles is discouraged 4

Relationship Between Varicoceles and Sexual Function

• The primary impact of varicoceles is on fertility parameters through mechanisms including:
  • Higher scrotal temperature
  • Testicular hypoxia
  • Reflux of toxic metabolites
  • Increased DNA damage 1
• While varicoceles can affect Leydig cell function and testosterone production in some men, the direct connection to erectile dysfunction and libido is not strongly established 5, 6
• The majority of men with varicoceles maintain normal sexual function, even with larger varicoceles 7

Hormonal Effects of Varicoceles

• Some studies have shown that varicoceles can lead to:
  • Lower testosterone levels in some men
  • Altered FSH and LH levels
  • Changes in other hormones like inhibin-B and Anti-Müllerian Hormone 8
• However, these hormonal changes are primarily associated with fertility issues rather than sexual dysfunction 6
• Not all men with varicoceles experience significant hormonal alterations 8

When to Consider Treatment

• Treatment of varicoceles is primarily indicated for:
  • Men with clinical varicoceles and abnormal semen parameters who are trying to conceive 1, 2
  • Men with a persistent small testis (size difference >2 mL or 20%) 1
• Varicocele repair is not routinely recommended for:
  • Subclinical (non-palpable) varicoceles 4, 2
  • Men with normal semen analysis 2
  • Sexual dysfunction without evidence of hypogonadism 6

Important Clinical Considerations

• If experiencing erectile dysfunction or low libido with a varicocele:
  • These symptoms are more likely due to other causes and should be evaluated separately 5
  • A comprehensive hormonal evaluation may be warranted to rule out hypogonadism 6
  • Consider other common causes of sexual dysfunction (cardiovascular disease, diabetes, psychological factors) 8
• For men with confirmed hypogonadism and varicocele:
  • Varicocelectomy may improve testosterone levels in some cases 6
  • This approach may be preferable to testosterone replacement therapy for men who wish to preserve fertility 6

Pitfalls to Avoid

• Attributing sexual dysfunction directly to a varicocele without proper evaluation of other more common causes 8
• Using ultrasound measurements alone to determine clinical significance of a varicocele 4
• Pursuing varicocele treatment solely for sexual dysfunction without evidence of hypogonadism 1, 6
• Overlooking the need for follow-up after varicocele repair, as hormonal improvements typically take 3-6 months 9