Varicoceles and Erectile Dysfunction
Varicoceles can cause erectile dysfunction, primarily through their association with hypogonadism (low testosterone), though the direct link to erectile dysfunction is less established than their well-documented effects on fertility. 1
Evidence for the Varicocele-Hypogonadism-ED Connection
The relationship between varicoceles and erectile dysfunction operates through hormonal mechanisms rather than direct vascular effects on penile function:
A 2024 meta-analysis demonstrated a significant association between varicocele and hypogonadism (OR 3.27,95% CI 1.23-8.68), establishing that men with varicoceles are over 3 times more likely to have low testosterone levels. 1
Men with bilateral grade 3 varicoceles show significantly decreased plasma testosterone levels, which can manifest as erectile dysfunction. 2
The pathophysiology involves testicular dysfunction affecting Leydig cell function, leading to impaired testosterone production through mechanisms including elevated scrotal temperature, testicular hypoxia, and reflux of toxic metabolites. 3, 4
Clinical Evidence on Erectile Function
The direct evidence linking varicoceles to erectile dysfunction is limited but suggestive:
Only one study in the 2024 systematic review showed a significant difference in erectile function between men with varicoceles versus those without, indicating that while erectile impairment can occur through hormonal disturbances, it is not universally present. 1
In a study of 15 men with bilateral grade 3 varicoceles presenting with erectile dysfunction (mean duration 3 ± 2.3 years), all had significantly decreased testosterone levels and excluded other organic or psychogenic causes. 2
Treatment Implications
Microsurgical varicocelectomy may be beneficial for men with clinically palpable varicoceles and documented hypogonadism who present with erectile dysfunction. 5
Key considerations for treatment:
Varicocelectomy yields significant testosterone improvements, particularly among hypogonadal men (mean increase of 93.7 ng/dL; 40.1% improvement), while eugonadal men show minimal changes (8.6 ng/dL; 2.01%). 6
Testosterone improvements are most pronounced in men with baseline testosterone <300 ng/dL and persist at 12-month follow-up. 6
Hormonal improvements parallel semen parameter improvements, typically taking 3-6 months (two spermatogenic cycles) to manifest. 7
Clinical Algorithm for Evaluation
When evaluating a patient with erectile dysfunction and suspected varicocele:
Perform physical examination to identify clinically palpable varicoceles (subclinical/non-palpable varicoceles should not be treated). 3, 4
Obtain at least two serum testosterone levels to document hypogonadism before considering surgical intervention. 5
Measure FSH and LH levels, as men with grade 3 varicoceles and erectile dysfunction may show significantly increased FSH and LH levels. 2
Assess testicular volume, as bilateral grade 3 varicoceles are associated with significantly decreased testicular size. 2
Important Caveats
The evidence linking varicoceles directly to erectile dysfunction is weaker than the evidence for their effects on fertility and testosterone levels. 1
Treatment should only target men with clinical (palpable) varicoceles and documented hypogonadism—not those with normal testosterone or subclinical varicoceles. 3, 7
The European Association of Urology recommends treating infertile men with clinical varicoceles and abnormal semen parameters, though guidelines specifically addressing erectile dysfunction as an indication are still evolving. 4
Men with baseline eugonadal testosterone levels (≥300 ng/dL) show minimal testosterone improvement after varicocelectomy and may not benefit from surgery for erectile dysfunction. 6