Scrotal Varicocele(varices) -Assessment & Treatment
Varicoceles are a common and potentially treatable cause of male infertility and scrotal discomfort. Mr. Jesuraj offers specialist assessment, fertility evaluation, and microsurgical treatment where appropriate, helping men make informed decisions about their care..
15%
of all men have a varicocele
35%
of men with infertility have a varicocele
60–70%
improvement in semen parameters after repair
#1
most common correctable cause of male infertility
UNDERSTANDING VARICOCELE
What Is a Varicocele?
A varicocele is an abnormal dilatation of the veins (pampiniform plexus) that drain blood from the testicle, essentially varicose veins within the scrotum. They are far more common on the left side (85–90% of cases) due to the anatomical difference in how the left testicular vein drains, but can be bilateral.
Varicoceles are found in approximately 15% of all men, but in up to 35% of men presenting with primary infertility and up to 80% of men with secondary infertility (those who have fathered a child before). This dramatic increase in prevalence among infertile men strongly suggests a causal relationship.
The mechanism of infertility is not fully understood but is thought to involve raised scrotal temperature, disrupted blood flow to the testis, oxidative stress, and hormonal effects, all of which impair spermatogenesis. Importantly, repair of the varicocele reverses these effects in many men, leading to measurable improvements in semen quality.
SIGNS & SYMPTOMS
Abnormal semen analysis
Low sperm count, poor motility or abnormal morphology — often the first sign.
Scrotal aching or heaviness
Dull discomfort that worsens when standing, exercising or at the end of the day — relieves when lying down.
Visible or palpable veins
A “bag of worms” sensation above the testicle — more obvious when standing or after a Valsalva manoeuvre.
Testicular atrophy
The affected testicle may be smaller than the other — a sign of impaired function that reversal can improve.
Often asymptomatic
Many varicoceles cause no pain and are found only during infertility investigation or routine examination.
ASSESSMENT
How We Assess Urinary Incontinence
Accurate assessment is the cornerstone of good incontinence management — the treatment depends entirely on the correct diagnosis.
SUBCLINICAL
Detected on Doppler Only
Not palpable or visible on examination — detected only by scrotal Doppler ultrasound. Clinical significance in infertility is debated. Surgery generally not recommended for subclinical varicocele alone.
GRADE I
Palpable on Valsalva Only
Felt only when the patient performs a Valsalva manoeuvre (straining/bearing down). Not visible. Mild varicocele — treatment depends on clinical context and semen analysis findings.
GRADE II
Palpable Without Valsalva
Readily felt on standing examination without straining. Moderate varicocele — associated with significantly impaired semen parameters in many men. Treatment typically recommended when fertility is affected.
GRADE III
Visible Through the Skin
Large varicocele visible on inspection — the classic “bag of worms.” Strongly associated with impaired semen analysis and testicular atrophy. Treatment recommended in most cases.
TREATMENT OPTIONS
The Full Range of Varicocele Treatments
Treatment choice depends on the grade, symptoms, fertility goals, and individual anatomy. Mr. Jesuraj offers all options and advises on the most appropriate approach for each patient.
Subinguinal Microsurgical Varicocelectomy
The gold standard — lowest recurrence rate, lowest complication rate
★ GOLD STANDARD
Subinguinal microsurgical varicocelectomy is the gold standard treatment for varicocele. Through a small incision just below the inguinal ligament, Mr. Jesuraj uses the Zeiss operating microscope at 15–25x magnification to identify, selectively ligate and divide the dilated internal spermatic veins — while carefully preserving the testicular artery, vas deferens, cremasteric vessels and lymphatics.
This precision is only achievable with the operating microscope. Non-microsurgical approaches — laparoscopic or open high ligation — carry significantly higher rates of:
Microsurgical varicocelectomy has the strongest evidence base for improving semen parameters and pregnancy rates — and is the approach used at the world’s leading male fertility centres.
APPROACH
Subinguinal (below groin crease)
MAGNIFICATION
Zeiss microscope 15–25x
ANAESTHETIC
Local or general anaesthetic
DURATION
45–90 min (bilateral: longer)
SETTING
Day case
RECURRENCE RATE
<5% (vs 15–20% non-microsurgical)
HYDROCELE RATE
<1% (vs 10–30% non-microsurgical)
RECOVERY
1–2 weeks
SEMEN REASSESSMENT
At 3 and 6 months post-op
Inguinal Varicocelectomy (Ivanissevich Procedure)
Open surgical ligation through the groin — an alternative when microsurgery is not required
STANDARD SURGICAL OPTION
SThe inguinal approach involves a groin incision to access and ligate the spermatic vein at a higher level. While effective, this approach does not offer the magnification of microsurgery and carries higher rates of hydrocele (due to lymphatic division) and recurrence compared to the microsurgical technique.
It remains a valid option in selected cases — for example, where anatomy, previous surgery or anaesthetic considerations make the subinguinal microsurgical approach less suitable. Mr. Jesuraj will always advise on the most appropriate approach for your specific situation.
APPROACH
Inguinal (groin) incision
ANAESTHETIC
General anaesthetic
DURATION
30–60 minutes
SETTING
Day case
RECURRENCE
Higher than microsurgical
RECOVERY
1–2 weeks
Radiological Embolisation
Minimally invasive — blocking the vein via a catheter under X-ray guidance
NON-SURGICAL OPTION
Percutaneous embolisation is performed by an interventional radiologist — not a surgeon. A catheter is inserted via the groin or neck vein and guided under X-ray to the testicular vein, which is then blocked using coils or sclerosant. No skin incision is required beyond the catheter entry point.
Advantages include a quicker return to normal activity and no surgical wound. Disadvantages include a higher technical failure rate, higher varicocele recurrence, and inability to identify and preserve the lymphatics (contributing to hydrocele risk). It is not typically recommended as first-line for men seeking fertility improvement — but may be appropriate in selected cases, particularly those with recurrent varicocele after previous surgery.
Mr. Jesuraj can refer patients for embolisation where this is the most appropriate option, and will discuss all the options transparently.
PERFORMED BY
Interventional radiologist
ANAESTHETIC
Local anaesthetic + sedation
RECOVERY
1–2 days
RECURRENCE
Higher than microsurgical
BEST FOR
Recurrent varicocele after surgery
Laparoscopic Varicocelectomy (Palomo Procedure)
Keyhole surgery through the abdomen — rarely recommended in current practice
RARELY RECOMMENDED
Laparoscopic varicocelectomy approaches the testicular vein from above, through small abdominal incisions. While it allows treatment of bilateral varicoceles through the same incisions, it requires general anaesthetic, carries the risks of abdominal surgery (bowel, vessel injury), and has a significant hydrocele rate — without the magnification benefits of microsurgery.
This approach has largely been superseded by microsurgical varicocelectomy in centres with microsurgical expertise. Mr. Jesuraj does not typically recommend laparoscopic varicocelectomy as first-line treatment.
APPROACH
Transabdominal keyhole
ANAESTHETIC
General anaesthetic
LIMITATIONS
No microsurgical magnification
CURRENT ROLE
Largely superseded by microsurgery
What to Expect After Varicocele Repair
Results depend on the grade of varicocele, baseline semen parameters, patient age and partner fertility — assessed individually during consultation.
Improvement in Semen Parameters
Significant improvement in sperm count, motility or morphology — typically seen at 3–6 months post-operatively as new sperm mature.
Spontaneous Pregnancy Rate
Natural pregnancy in couples with no other identified fertility factor — often achieved within 12 months of surgery.
Time to See Results
Spermatogenesis takes approximately 72 days — improvement in semen analysis is typically seen at the 3-month recheck, with further gains by 6 months.
Reduction in Scrotal Pain
For men with symptomatic varicocele (aching, heaviness) — significant pain improvement is reported in the majority of patients.
* Results vary between individuals. Mr. Jesuraj will give you a personalised assessment of your likely outcome based on your specific findings, semen analysis, partner fertility and time to conception goal.
From Diagnosis to Recovery
Assessment
Consultation, examination and scrotal Doppler ultrasound. Semen analysis if fertility is the concern. Grade and clinical significance assessed.
Treatment Decision
Full discussion of all options — microsurgical repair, embolisation, or watchful waiting. Decision made together based on your goals and anatomy.
Surgery
Day case procedure. Mr. Jesuraj performs microsurgical repair under the Zeiss microscope. Home same day — rest for 1–2 weeks.
Semen Recheck
Semen analysis at 3 and 6 months. Results reviewed with Mr. Jesuraj. Further planning if needed — including IVF if parameters remain poor.
Interested?
Book a consultation with Mr. Jesuraj to find out if you are a suitable candidate. Appointments available within days.
Treatments — Male Fertility & Scrotal Surgery
Varicocele Treatment — Microsurgical Repair & Beyond
A varicocele is the most common correctable cause of male infertility. Mr. Jesuraj offers the full range of treatment options — including gold standard microsurgical varicocelectomy — for both infertility and scrotal pain.
Understanding Varicocele
What Is a Varicocele?
A varicocele is an abnormal dilatation of the veins (pampiniform plexus) that drain blood from the testicle — essentially varicose veins within the scrotum. They are far more common on the left side (85–90% of cases) due to the anatomical difference in how the left testicular vein drains, but can be bilateral.
Varicoceles are found in approximately 15% of all men — but in up to 35% of men presenting with primary infertility and up to 80% of men with secondary infertility (those who have fathered a child before). This dramatic increase in prevalence among infertile men strongly suggests a causal relationship.
The mechanism of infertility is not fully understood but is thought to involve raised scrotal temperature, disrupted blood flow to the testis, oxidative stress, and hormonal effects — all of which impair spermatogenesis. Importantly, repair of the varicocele reverses these effects in many men, leading to measurable improvements in semen quality.
Signs & Symptoms
Low sperm count, poor motility or abnormal morphology — often the first sign.
Dull discomfort that worsens when standing, exercising or at the end of the day — relieves when lying down.
A “bag of worms” sensation above the testicle — more obvious when standing or after a Valsalva manoeuvre.
The affected testicle may be smaller than the other — a sign of impaired function that reversal can improve.
Many varicoceles cause no pain and are found only during infertility investigation or routine examination.
Classification
Varicocele Grading — Clinical & Subclinical
Varicoceles are classified by how they are detected. Grade influences management decisions.
Subclinical
Detected on Doppler Only
Not palpable or visible on examination — detected only by scrotal Doppler ultrasound. Clinical significance in infertility is debated. Surgery generally not recommended for subclinical varicocele alone.
Grade I
Palpable on Valsalva Only
Felt only when the patient performs a Valsalva manoeuvre (straining/bearing down). Not visible. Mild varicocele — treatment depends on clinical context and semen analysis findings.
Grade II
Palpable Without Valsalva
Readily felt on standing examination without straining. Moderate varicocele — associated with significantly impaired semen parameters in many men. Treatment typically recommended when fertility is affected.
Grade III
Visible Through the Skin
Large varicocele visible on inspection — the classic “bag of worms.” Strongly associated with impaired semen analysis and testicular atrophy. Treatment recommended in most cases.
Treatment Options
The Full Range of Varicocele Treatments
Treatment choice depends on the grade, symptoms, fertility goals, and individual anatomy. Mr. Jesuraj offers all options and advises on the most appropriate approach for each patient.
Subinguinal Microsurgical Varicocelectomy
The gold standard — lowest recurrence rate, lowest complication rate
Subinguinal microsurgical varicocelectomy is the gold standard treatment for varicocele. Through a small incision just below the inguinal ligament, Mr. Jesuraj uses the Zeiss operating microscope at 15–25x magnification to identify, selectively ligate and divide the dilated internal spermatic veins — while carefully preserving the testicular artery, vas deferens, cremasteric vessels and lymphatics.
This precision is only achievable with the operating microscope. Non-microsurgical approaches — laparoscopic or open high ligation — carry significantly higher rates of:
- Hydrocele formation (10–30% non-microsurgical vs <1% microsurgical)
- Testicular artery injury and testicular atrophy
- Varicocele recurrence (15–20% vs <5% microsurgical)
Microsurgical varicocelectomy has the strongest evidence base for improving semen parameters and pregnancy rates — and is the approach used at the world’s leading male fertility centres.
Inguinal Varicocelectomy (Ivanissevich Procedure)
Open surgical ligation through the groin — an alternative when microsurgery is not required
The inguinal approach involves a groin incision to access and ligate the spermatic vein at a higher level. While effective, this approach does not offer the magnification of microsurgery and carries higher rates of hydrocele (due to lymphatic division) and recurrence compared to the microsurgical technique.
It remains a valid option in selected cases — for example, where anatomy, previous surgery or anaesthetic considerations make the subinguinal microsurgical approach less suitable. Mr. Jesuraj will always advise on the most appropriate approach for your specific situation.
Radiological Embolisation
Minimally invasive — blocking the vein via a catheter under X-ray guidance
Percutaneous embolisation is performed by an interventional radiologist — not a surgeon. A catheter is inserted via the groin or neck vein and guided under X-ray to the testicular vein, which is then blocked using coils or sclerosant. No skin incision is required beyond the catheter entry point.
Advantages include a quicker return to normal activity and no surgical wound. Disadvantages include a higher technical failure rate, higher varicocele recurrence, and inability to identify and preserve the lymphatics (contributing to hydrocele risk). It is not typically recommended as first-line for men seeking fertility improvement — but may be appropriate in selected cases, particularly those with recurrent varicocele after previous surgery.
Mr. Jesuraj can refer patients for embolisation where this is the most appropriate option, and will discuss all the options transparently.
Laparoscopic Varicocelectomy (Palomo Procedure)
Keyhole surgery through the abdomen — rarely recommended in current practice
Laparoscopic varicocelectomy approaches the testicular vein from above, through small abdominal incisions. While it allows treatment of bilateral varicoceles through the same incisions, it requires general anaesthetic, carries the risks of abdominal surgery (bowel, vessel injury), and has a significant hydrocele rate — without the magnification benefits of microsurgery.
This approach has largely been superseded by microsurgical varicocelectomy in centres with microsurgical expertise. Mr. Jesuraj does not typically recommend laparoscopic varicocelectomy as first-line treatment.
Expected Outcomes
What to Expect After Varicocele Repair
Results depend on the grade of varicocele, baseline semen parameters, patient age and partner fertility — assessed individually during consultation.
Improvement in Semen Parameters
Significant improvement in sperm count, motility or morphology — typically seen at 3–6 months post-operatively as new sperm mature.
Spontaneous Pregnancy Rate
Natural pregnancy in couples with no other identified fertility factor — often achieved within 12 months of surgery.
Time to See Results
Spermatogenesis takes approximately 72 days — improvement in semen analysis is typically seen at the 3-month recheck, with further gains by 6 months.
Reduction in Scrotal Pain
For men with symptomatic varicocele (aching, heaviness) — significant pain improvement is reported in the majority of patients.
* Results vary between individuals. Mr. Jesuraj will give you a personalised assessment of your likely outcome based on your specific findings, semen analysis, partner fertility and time to conception goal.
Your Journey
From Diagnosis to Recovery
Assessment
Consultation, examination and scrotal Doppler ultrasound. Semen analysis if fertility is the concern. Grade and clinical significance assessed.
Treatment Decision
Full discussion of all options — microsurgical repair, embolisation, or watchful waiting. Decision made together based on your goals and anatomy.
Surgery
Day case procedure. Mr. Jesuraj performs microsurgical repair under the Zeiss microscope. Home same day — rest for 1–2 weeks.
Semen Recheck
Semen analysis at 3 and 6 months. Results reviewed with Mr. Jesuraj. Further planning if needed — including IVF if parameters remain poor.
Don’t Let a Varicocele Delay Your Family
Appointments at Best Life Clinic, Stockton-on-Tees — Monday, Thursday and Friday. Most patients seen within 7 days. No GP referral required.