Summary
Definition
History and exam
Key diagnostic factors
- presence of risk factors
- painless scrotal mass
- left-sided signs/symptoms
- small testicle
Other diagnostic factors
- subfertility/infertility
- age over 12 years
- scrotal or groin pain
Risk factors
- somatometric parameters (tall/low BMI)
- family history of varicocele
Diagnostic investigations
1st investigations to order
- clinical diagnosis
Investigations to consider
- scrotal ultrasound with colour flow Doppler imaging
- semen analysis
- serum follicle-stimulating hormone (FSH) (± GnRH stimulation)
- serum testosterone
- DNA fragmentation index (DFI)
- CT abdomen/pelvis
- MRI abdomen/pelvis
- retroperitoneal ultrasound
Treatment algorithm
adolescent
adult
Contributors
Authors
Jay Ira Sandlow, MD
Professor and Chair
Department of Urology
Medical College of Wisconsin
Milwaukee
WI
Disclosures
JIS declares that he has received stock options as a member of the Scientific Advisory Board for Contraline, Inc. and has served as a faculty member on the Vasectomy course for the American Urological Association.
Daniel L. Pelzman, MD
Assistant Professor
Massachusetts General Hospital
Boston
MA
Disclosures
DLP declares that he has no competing interests.
Acknowledgements
Dr Jay Ira Sandlow and Dr Daniel L. Pelzman would like to gratefully acknowledge Dr Jagan K. Kansal, Dr Pravin Rao, Dr Miguel Pineda, Dr John C. Thomas, and Dr Wayne Kuang, previous contributors to this topic.
Disclosures
JKK, PR, MP, JCT, and WK declare that they have no competing interests.
Peer reviewers
Siam Oottamasathien, MD
Assistant Professor
Division of Pediatric Urology
University of Utah
Primary Children's Medical Center
Salt Lake City
UT
Disclosures
SO declares that she has no competing interests.
Jeffrey Donohoe, MD
Assistant Professor
Pediatric Urology
Medical College of Georgia
Augusta
GA
Disclosures
JD declares that he has no competing interests.
Daniel H. Williams, MD
Assistant Professor
Department of Urology
Head
Section of Male Infertility and Andrology
University of Wisconsin School of Medicine and Public Health
Madison
WI
Disclosures
DHW declares that he has no competing interests.
Edmund Sabanegh, Jr, MD
Director
Center for Male Fertility
Glickman Urological and Kidney Institute
Cleveland
OH
Disclosures
ES declares that he has no competing interests.
References
Key articles
Brannigan RE, Hermanson L, Kaczmarek J, et al. Updates to male infertility: AUA/ASRM guideline (2024). J Urol. 2024 Dec;212(6):789-99. Abstract
European Association of Urology. Sexual and reproductive health guidelines. Apr 2025 [internet publication].Full text
Persad E, O'Loughlin CA, Kaur S, et al. Surgical or radiological treatment for varicoceles in subfertile men. Cochrane Database Syst Rev. 2021 Apr 23;4:CD000479.Full text Abstract
European Association of Urology. Guidelines on paediatric urology. Apr 2024 [internet publication].Full text
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Paratesticular mass
- Cord hydrocele
- Inguinal hernia
More DifferentialsGuidelines
- Sexual and reproductive health: male infertility
- Diagnosis and treatment of infertility in men
More GuidelinesPatient information
Fertility problems: some reasons
Fertility problems: questions to ask your doctor
More Patient information
Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer