Varicocele: Prevention, Diagnosis, and When to See a Doctor

Varicocele cannot be “trained away” or “worked off,” but it can be noticed in time, examined correctly, and prevented from quietly worsening fertility. The editorial team has put together a practical overview: what really depends on the athlete, what modern diagnosis looks like, and in which situations a doctor should be seen without delay.

Is prevention possible

Varicocele is mostly caused by the anatomy of venous drainage and congenital valve insufficiency, so primary prevention in the classic sense does not exist. No training regimen, supplement, or underwear guarantees that varicocele will not appear. Honestly acknowledging this is the first step toward a sensible approach.

Instead, it is possible to influence two things: how early the condition is detected and additional factors that worsen testicular function. Early self-examination and regular preventive check-ups in adolescence and young adulthood make it possible to notice varicocele while it is still possible to assess the dynamics of testicular growth and sperm quality.

Modifiable factors include overheating of the scrotum (long saunas, hot baths, prolonged sitting with a laptop on the lap, very tight synthetic clothing), smoking, excess body weight, and, especially, hormonal drugs that suppress spermatogenesis. These factors do not cause varicocele, but they can deepen its effect on fertility.

In the training process, people with an already detected varicocele are sometimes advised to avoid prolonged straining with breath-holding and to control breathing technique during heavy sets. This is a reasonable precaution, although the evidence base here is limited, and the decision about restrictions should be made together with a doctor.

• monthly self-examination of the scrotum after a warm shower;
• avoiding prolonged overheating and tight clothing;
• quitting smoking and controlling body weight;
• refusing to take androgens on one's own, especially when planning to have children;
• rational breathing technique during maximal loads.

How the doctor makes the diagnosis

The basis of diagnosis remains the physical examination. The urologist examines and palpates the scrotum in a warm room, in a standing position — first at rest, then during the Valsalva maneuver (straining). In a lying position, the dilated veins in primary varicocele usually collapse; if this does not happen, the doctor will look for a secondary cause.

During the examination the size and consistency of the testicles are also assessed. A decrease in the volume of the testicle on the side of the varicocele is of great importance, especially in adolescents: a volume difference of more than roughly 20% is considered a sign that varicocele is affecting the development of the organ.

Ultrasound examination with color Doppler mapping confirms the diagnosis, measures the diameter of the veins, and registers the reverse blood flow (reflux) during the Valsalva maneuver. It also allows the testicular volume to be measured precisely and other masses to be ruled out. Subclinical varicocele, visible only on ultrasound, usually does not require treatment according to the guidelines of the European Association of Urology.

For a sudden, right-sided varicocele or one that does not collapse when lying down, the doctor will order an ultrasound or another imaging study of the kidneys and retroperitoneal space, so as not to miss a tumor or thrombosis.

Assessment of fertility and hormones

For an adult man with clinical varicocele, the key test is the semen analysis. It is evaluated by the criteria of the World Health Organization, and for a reliable conclusion at least two analyses with an interval of a few weeks are usually needed, since sperm quality fluctuates considerably.

Before giving a semen analysis, abstinence for a few days (usually 2–7) is observed, and fever, sauna, and alcohol are avoided. A recent illness with a high temperature can worsen the results for several months, since the cycle of spermatogenesis lasts about 70–80 days.

The hormonal examination includes luteinizing and follicle-stimulating hormones, total testosterone, and, if needed, prolactin and estradiol. An elevated FSH indicates damage to the spermatogenic epithelium, while low LH and FSH together with low testosterone in an athlete is a typical picture of suppression of the hormonal axis by exogenous androgens.

That is why honest information about taking any hormonal drugs is fundamentally important for the doctor. Without it, it is easy to mistakenly link a poor semen analysis to varicocele alone and to make a decision about surgery, which will not solve the problem as long as the hormonal suppression continues.

When to see a doctor

A scheduled consultation with a urologist or andrologist is needed if you have noticed dilated veins or “nodules” above the testicle, feel a pulling pain that worsens after training and standing, or if a couple does not achieve pregnancy over a year of regular sexual relations without contraception.

In adolescents, any varicocele is a reason for examination: the doctor will assess whether the testicle on the affected side is lagging in growth and will determine the frequency of follow-up examinations. Parents of young athletes should remember this during medical boards.

Emergency help should be sought for sudden severe pain in the testicle (torsion is possible), rapid enlargement of the scrotum after an injury, the appearance of a hard nodule in the testicle itself, as well as for a sudden right-sided varicocele or one that does not decrease when lying down.

Treatment and return to training

According to the guidelines of the European Association of Urology and the American Society for Reproductive Medicine, treatment of varicocele is indicated primarily for the combination of a clinically detected varicocele, semen abnormalities, and infertility in a couple. It is also considered in adolescents with persistent lagging of testicular growth and in pronounced pain that does not go away.

The main methods are microsurgical varicocelectomy, laparoscopic surgery, and endovascular embolization of the testicular vein. The microsurgical approach is associated with a lower rate of recurrence and hydrocele. The choice of method depends on the anatomy, the clinic's experience, and the patient's preferences.

The effect of treatment on sperm is assessed no earlier than 3–6 months, since it takes exactly that long for spermatogenesis to fully renew. Surgery does not improve the parameters in all patients, and in subclinical varicocele no benefit has been proven.

The return to training after an intervention is determined by the surgeon. Usually recovery is shorter after embolization, and after open or microsurgical surgery heavy strength loads are postponed for a few weeks. Rushing back to maximal weights increases the risk of complications in the area of the intervention.

Editorial conclusions

It is impossible to prevent varicocele itself, but it can be detected in time and the effect of additional harmful factors — overheating, smoking, hormonal drugs — can be reduced.

Diagnosis is based on examination standing with the Valsalva maneuver, Doppler ultrasound, semen analysis, and a hormonal profile. It is fundamentally important for the doctor to know about all drugs that affect the hormonal axis.

Treatment is not indicated for everyone: the main criteria are sperm abnormalities with infertility, lagging testicular growth in adolescents, and pronounced pain. Sudden pain, a sudden right-sided varicocele, or a nodule in the testicle are reasons for an urgent visit.

We also recommend reading our materials on the causes of varicocele in athletes, on interpreting a semen analysis, and on the hormones LH and FSH.

References

1. Minhas S, Bettocchi C, Boeri L, et al. European Association of Urology Guidelines on Male Sexual and Reproductive Health: 2021 Update on Male Infertility. Eur Urol. 2021;80(5):603–620.
2. Practice Committee of the American Society for Reproductive Medicine. Report on varicocele and infertility: a committee opinion. Fertil Steril. 2014;102(6):1556–1560.
3. Jensen CFS, Østergren P, Dupree JM, et al. Varicocele and male infertility. Nat Rev Urol. 2017;14(9):523–533.
4. World Health Organization. WHO laboratory manual for the examination and processing of human semen. 6th ed. Geneva: WHO; 2021.
5. Dubin L, Amelar RD. Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Fertil Steril. 1970;21(8):606–609.
6. Rahnema CD, Lipshultz LI, Crosnoe LE, et al. Anabolic steroid-induced hypogonadism: diagnosis and treatment. Fertil Steril. 2014;101(5):1271–1279.