Can subclinical varicoceles (varicose veins in the scrotum) cause testicular atrophy in younger to middle-aged males, particularly those with a history of infertility or subfertility issues?

Can Subclinical Varicoceles Cause Testicular Atrophy?

No, subclinical varicoceles should not be treated for testicular atrophy concerns, as they do not play a major role in male infertility or testicular damage, and treatment of subclinical varicoceles is not effective at improving fertility outcomes or preventing testicular atrophy. 1, 2, 3

Evidence-Based Distinction Between Clinical and Subclinical Varicoceles

Clinical Varicoceles and Testicular Atrophy

• Clinical (palpable) varicoceles are associated with testicular atrophy, with studies demonstrating that left testicular volume is significantly reduced compared to the right testis (12.9 mL versus 14.1 mL) in men with clinical left varicoceles 4
• The European Association of Urology strongly recommends surgery for varicocele when associated with persistent testicular size difference >2 mL or 20%, confirmed on two subsequent visits 6 months apart 2, 5
• The pathophysiology involves higher scrotal temperature, testicular hypoxia, and reflux of toxic metabolites causing testicular dysfunction through increased DNA damage and oxidative stress 1, 5, 6

Subclinical Varicoceles Do NOT Cause Clinically Significant Atrophy

• Subclinical varicoceles detected only by ultrasound are associated with decreased left testicular volume (13.2 mL versus 14.7 mL), but this finding does not translate to clinical significance 4
• Treatment of subclinical varicoceles is not effective at increasing chances of spontaneous pregnancy and should not be pursued 1, 2, 5, 6
• The literature clearly states that subclinical varicoceles do not play a major role in male infertility 3
• Routine use of ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of these subclinical varicoceles is not associated with improvement in either semen parameters or fertility rates 2, 6

Clinical Algorithm for Management

When to Intervene for Testicular Atrophy

Only treat if ALL of the following criteria are met:

• Palpable varicocele on physical examination (not just ultrasound-detected) 2, 5, 6
• Testicular size difference >2 mL or 20% 2, 5
• Confirmed on two separate visits 6 months apart 2, 5
• Abnormal semen parameters or documented fertility concerns 5, 6

What NOT to Do

• Do not treat subclinical varicoceles detected only by imaging, regardless of testicular size differences 1, 2, 5, 6
• Do not treat men with normal semen parameters, even if they have a palpable varicocele 2, 6
• Do not routinely perform scrotal ultrasound to look for non-palpable varicoceles 2, 6

Important Caveats

Progressive Nature in Clinical Varicoceles Only

• Clinical varicoceles may exert a progressive toxic effect on the testes that can result in irreversible infertility if left untreated 7
• Varicoceles occur with greater frequency in men with secondary infertility (69%) compared to primary infertility (50%), suggesting progressive damage over time in clinical varicoceles 8
• However, this progressive deterioration applies only to clinical (palpable) varicoceles, not subclinical ones 3

Reversibility with Appropriate Treatment

• Varicocelectomy can reverse sperm DNA damage and improve oxidative stress levels, suggesting the pathophysiological processes are potentially reversible 5
• Improvements in testicular volume and semen parameters typically occur within 3-6 months (two spermatogenic cycles) after surgery for clinical varicoceles 2, 5, 6

Adolescent Considerations

• In adolescents with clinical varicoceles, testicular atrophy is the main clinical indication for repair when semen analysis is not available 9
• The same criteria apply: persistent size difference >2 mL or 20% confirmed on two visits 6 months apart 2, 5