Varicocele: Scrotal aching and heaviness that worsens with prolonged standing—when does it require treatment?
Varicocele: Scrotal aching and heaviness that worsens with prolonged standing—when does it require treatment?
Article Summary
I. Dull Pain in the Scrotum, More Pronounced When Standing Long: What Could Be the Problem?
Varicocele is the dilation of veins in the scrotum where the valves fail to close properly, leading to poor blood flow. Most cases occur on the left side, though it can be bilateral.
A common sensation is a dragging or dull ache, which becomes more noticeable after standing, walking, or exercising for a long time, and is relieved by lying down. Some people discover it when they feel a bundle of blood vessels resembling a "bag of worms" above the scrotum on their own. Others have no symptoms at all and only find out during health checkups or other medical examinations.
Having no symptoms does not mean treatment is necessary, and having symptoms does not mean varicocele is the definite cause. There are multiple sources of scrotal pain; having a physician confirm the cause is the first step.
II. How Do Physicians Confirm It?
Diagnosis relies on physical examinations combined with scrotal Doppler ultrasound.
International guidelines consider a vein diameter of over 3 mm with reflux lasting more than 2 seconds during the Valsalva maneuver (bearing down) in a standing position to be of clinical significance.
If it appears solely on the right side, further evaluation of the abdominal and retroperitoneal cavities is necessary to rule out other causes of venous obstruction. This is easily overlooked in outpatient clinics, yet this indicator affects the direction of subsequent management.
III. Not Every Symptom Requires Treatment
Usually, asymptomatic cases only require observation and follow-up.
If pain is present, conservative treatment can be arranged first. This includes reducing prolonged standing, using supportive underwear, and taking pain relievers when necessary.
If conservative treatment continues for a period but pain persists, then management options are discussed. International guidelines list "persistent scrotal pain unresponsive to conservative treatment" as one of the indications for intervention.
IV. Management Methods
Interventions are divided into surgical ligation and catheter embolization. Dr. Chun-Yu Lin at Shyi Clinic performs catheter embolization.
Procedure Overview
Performed under local anesthesia, a thin catheter is introduced through an artery in the groin and guided under imaging to the relevant position of the spermatic vein. Surgical consumables and catheters do not touch the external genitalia, and patients can go home the same day without hospitalization.
Why Venography is Done During the Treatment
Everyone's blood vessel pathway is different. Scrotal ultrasound can detect whether veins are dilated, whether there is reflux, and the blood flow status of the testicles, but it only assesses locally. During the actual catheter procedure, the physician needs to know the entire venous return pathway and where the abnormal branches are located.
Venography is performed during the procedure by injecting contrast medium through the catheter to observe the actual blood flow under X-ray imaging. The purpose is to identify the specific blood vessels causing the reflux, rather than simply viewing what the vessels look like.
Embolization Materials
The materials are chosen based on vessel morphology and the physician's judgment. Coils are commonly used to block abnormal blood flow by forming a thrombus. In some cases, other embolic materials are combined. The actual materials and quantity used are decided by the physician based on the vessel conditions observed during the venography.
Goal of Treatment
The goal is to block the specific segment of the vein causing reflux, not to block all normal blood vessels. The testicle has multiple pathways for venous return, and after treatment, blood is redirected through other normal pathways.
V. Efficacy and Limitations
According to international literature reports, the proportion of patients who experience a reduction in pain after embolization ranges from approximately 70% to 90%. The success definitions and follow-up periods vary across studies, which accounts for the differences in these figures.
The same set of data also indicates that those with moderate or severe baseline pain show a higher improvement rate, while a considerable proportion of those with only mild discomfort feel no significant difference. This is an important point to discuss clearly during the outpatient consultation.
Regarding the technical aspect, a 15-year retrospective report of 225 cases showed a technical success rate of 96%. The recurrence rate reported in various studies ranges from about 3% to 13%. Recurrence may be due to undetected abnormal branches or newly formed reflux pathways, making post-operative follow-up vital.
Symptom improvement takes time and does not happen immediately after the procedure. The same applies to changes in the physical appearance of the veins.
VI. Risks and Potential Discomforts
Any vascular intervention carries risks.
Literature reports show a low complication rate, with data from 225 cases over 15 years being 1.78%, and no major adverse events occurred. Potential issues include left renal vein thrombosis, pampiniform plexus thrombophlebitis, migration of embolic materials, and technical failure in positioning the catheter.
The procedure utilizes X-ray guidance and contrast media throughout, which involves radiation exposure and potential contrast-related reactions. Patients with a history of contrast allergy or kidney disease should inform the medical staff beforehand.
Short-term discomforts after the procedure may include bruising and mild swelling/pain at the puncture site, dull aches in the lower abdomen or groin, temporary discomfort in the scrotal area, and fatigue. These typically resolve gradually.
VII. If Your Concern is Related to Fertility
Varicoceles are frequently discovered clinically during infertility evaluations.
Fertility-related evaluation priorities and treatment options differ from those for pain, and they also involve semen analysis and evaluations of the partner. It is recommended to consult with a urology or reproductive medicine clinic first before deciding on subsequent steps.
VIII. Frequently Asked Questions
Will the blood have nowhere to flow after embolization?
No. The testicle has multiple pathways for venous return. The goal of the procedure is to block the segment with abnormal reflux, and blood will flow back through other normal pathways.
Will the varicocele disappear immediately after embolization?
Not necessarily. The appearance of the veins and the symptoms require time to gradually change. Please follow up as arranged by your physician.
Will it affect testicular function?
The procedure targets the abnormal venous reflux and is not meant to block the normal blood supply to the testicles. Individual risks are assessed based on personal vascular anatomy and the treatment method.
Will it recur after treatment?
It is possible. Literature reports show a recurrence rate of about 3% to 13%. Some patients may have undetected abnormal branches or develop new reflux pathways, which makes regular post-operative follow-up extremely important.
How long does the procedure take? Can I arrange other plans on the same day?
The exact duration of the catheter procedure cannot be precisely predicted in advance.
Vascular anatomy, the degree of reflux, the location of abnormal branches, and the embolization process must all be assessed in real-time based on intraoperative imaging. It is recommended not to schedule hurried itineraries or important work on the day of the procedure, and to reserve time for rest. You can return home on the same day after post-operative observation.
Author: Dr. Chun-Yu Lin
Last Updated: August 25, 2026
The case studies in this article have been de-identified. This article is for general health education information and cannot replace professional medical diagnosis and treatment advice. Individual diagnosis must still be confirmed by complete medical history and dynamic vascular examinations.
References
European Association of Urology. EAU Guidelines on Sexual and Reproductive Health — Male Infertility. 2025 update. European Urology.
Korean Society for Sexual Medicine and Andrology. Recent Guidelines and Perspectives for Varicocele: A Clinical Consensus and Recommendations. World Journal of Men's Health. 2025.
Muthuveloe DW, During V, Ashdown D, Rukin NJ, Jones RG, Patel P. The effectiveness of varicocele embolisation for the treatment of varicocele related orchalgia. SpringerPlus. 2015;4:392. DOI: 10.1186/s40064-015-1177-2
Sheehan M, et al. Pain relief after varicocele embolization: The patient's perspective. Journal of Medical Imaging and Radiation Oncology. 2020. DOI: 10.1111/1754-9485.13001
Percutaneous Embolization for Painful Varicocele: An 8-Year Tertiary Centre Experience. Journal of the Belgian Society of Radiology. 2025. DOI: 10.5334/jbsr.3769
A fifteen-year retrospective analysis of varicocele embolization: evaluating success, recurrence rates and embolic agents. CVIR Endovascular. 2025. DOI: 10.1186/s42155-025-00575-6
Kasunic D, et al. Comparing the efficacy of different embolisation materials in improving pain and fertility outcomes in patients with varicoceles: A systematic review. Journal of Medical Imaging and Radiation Oncology. 2025;69(1):112-125. DOI: 10.1111/1754-9485.13801
