If your doctor or scan report has given your varicocele a number, you may be wondering what it means. Varicocele grades describe how large or how easy to find a varicocele is. There are two main kinds: grades from a physical examination, which run from 0 to 3, and grades from an ultrasound scan, which often run from 1 to 5. This guide explains both, what a “grade 4” means, and whether your grade changes the treatment you are offered.
For the basics of the condition, see our varicocele overview.
Why varicoceles are graded
A varicocele is a cluster of widened veins above the testicle, caused by faulty valves that let blood pool. Varicoceles range from tiny ones that only a scan can find to large ones you can see through the skin.
Grading gives doctors a shared language. It helps them describe a varicocele, compare it over time and decide whether it counts as “clinical”, meaning it can be felt. But a grade is only one piece of the picture. A small varicocele can still ache, and a large one may cause no trouble.
Clinical grades: 0 to 3
The most widely used clinical system is based on a 1970 grading by Dubin and Amelar, with grade 0 added later for varicoceles found only on ultrasound. The doctor examines you standing up, in a warm room, and asks you to hold your breath and bear down (the Valsalva manoeuvre).
| Grade | Name | What the doctor finds |
|---|---|---|
| 0 | Subclinical | Cannot be felt or seen. Found only on ultrasound. |
| 1 | Small | Can be felt only when you bear down. |
| 2 | Medium | Can be felt while standing, without bearing down, but cannot be seen. |
| 3 | Large | Can be seen through the skin of the scrotum. |
Varicocele grade 1
A grade 1 varicocele is small. It is easy to miss and depends a lot on the examiner and the room temperature. Because it can be felt, it still counts as a clinical varicocele.
Varicocele grade 2
A grade 2 varicocele can be felt as soft, twisted cords above the testicle when you stand, without straining. It cannot be seen. This is one of the most common grades found during fertility checks.
Grade 3
A grade 3 varicocele is large enough to see. It often looks like a “bag of worms” of bluish veins above the testicle, and it shrinks when you lie down. Larger varicoceles are more likely to cause an ache and to be linked with a smaller testicle, but this is not always the case.
Varicocele ultrasound: how scans grade a varicocele
A scrotal ultrasound with Doppler, which shows the direction of blood flow, confirms the diagnosis and checks the size of the testicles. European radiology guidance (ESUR-SPIWG) recommends scanning both lying down and standing, while you bear down. Key measurements are:
- Vein width. The widest vein, measured standing and while straining. A width of 3 mm or more is usually taken as a sign of a varicocele.
- Reflux. Blood flowing backwards down the vein. Reflux lasting more than 2 seconds while standing and straining is considered abnormal. Reflux matters more than vein size for predicting whether repair will help fertility.
- Testicle size. Each testicle is measured, because a smaller testicle on the affected side can influence treatment decisions.
Sarteschi ultrasound grades 1 to 5
There is no single agreed ultrasound scale, and several exist. The one most often seen, and the one the European guidance says may be helpful, is the Sarteschi classification. In plain words:
- Grade 1. Backflow in the groin only while straining. The veins are not enlarged.
- Grade 2. Small widened veins above the testicle, with backflow only while straining.
- Grade 3. Widened veins reaching down around the testicle when standing, with backflow only while straining. The veins look normal lying down.
- Grade 4. Veins widened even when lying down, getting bigger when straining. Backflow at rest that increases with straining. The testicle may be smaller.
- Grade 5. Veins widened lying and standing, with backflow at rest that does not increase with straining. The testicle is often smaller, and widened veins may be seen inside it.
What does “grade 4” mean?
Grade 4 is not part of the standard clinical scale, which stops at grade 3. If your report says “grade 4” or “grade 5”, it is almost certainly using an ultrasound scale such as Sarteschi’s. Some clinics use other ultrasound scales with different numbers, so ask your doctor which system was used.
People often search for “varicocele grade 4 symptoms”. The symptoms are the same as for any varicocele: often none, sometimes a dull, dragging ache that builds after standing and eases lying down, a heavy feeling, or a testicle that is smaller. A high ultrasound grade does not mean the varicocele is dangerous. Read more about varicocele symptoms.
Does the grade change treatment?
Less than you might expect. The ESUR-SPIWG review found that grading systems are not good at predicting how much a varicocele affects sperm, or how much repair will help. Doctors weigh the grade alongside:
- Pain. An ache that keeps returning and affects daily life may be treated at any clinical grade, once other causes have been ruled out.
- Fertility. European Association of Urology guidelines recommend treatment for men with a clinical varicocele (grade 1 to 3), an abnormal semen test and otherwise unexplained infertility. They advise against treating men with a normal semen test, or a grade 0 varicocele seen only on a scan. See varicocele and fertility.
- Teenagers. The main reason to treat is a testicle on the affected side that stays clearly smaller than the other on repeat checks some months apart. Teenagers with a varicocele who are not treated are usually followed up.
Grade 1, grade 2 and grade 3 treatment
There is no separate treatment for each grade. If treatment is needed, the options are the same: microsurgical or keyhole surgery to tie off the veins, or embolisation, which blocks the vein from the inside through a needle hole. Compare them in our guides to varicocele treatment and varicocele embolisation.
Can a grade change over time?
Most varicoceles in adults stay much the same for years. In teenagers, a varicocele can grow as the body develops, which is one reason for regular checks. After treatment, an ultrasound can show whether backflow has stopped.
When to see a doctor
See a doctor if you notice a new lump or swelling in your scrotum, have an ache that keeps coming back, notice that one testicle is smaller, or have been trying for a baby for a year without success. If your report gives a grade you do not understand, ask your doctor to explain it.
Sudden, severe pain in a testicle is an emergency. It may be testicular torsion, where the testicle twists and loses its blood supply, and it needs treatment within hours. Get urgent help too for testicle pain with vomiting or tummy pain, or a hot, red, swollen scrotum with fever. In Singapore, call 995 in an emergency.
Frequently asked questions
What are the varicocele grades?
In the common clinical system, grade 0 can only be seen on ultrasound, grade 1 can be felt only when you bear down, grade 2 can be felt while standing without bearing down, and grade 3 can be seen through the skin of the scrotum. Ultrasound reports may also use a five-grade scale.
What are varicocele grade 4 symptoms?
There is no grade 4 in the standard clinical system. If your report says grade 4, it is probably using an ultrasound scale, where grade 4 means the veins are widened even when lying down, with backflow at rest. Symptoms are the same as any varicocele: often none, sometimes a dull ache that builds after standing, a heavy feeling or a smaller testicle.
Does a grade 2 varicocele need treatment?
Not usually on its own. A grade 2 varicocele is treated if it causes an ache that affects daily life, if it is linked with fertility problems and an abnormal semen test, or if a teenager's testicle on that side is not growing properly. Otherwise, it is usually just watched.
Does a grade 1 varicocele need treatment?
Most grade 1 varicoceles need no treatment. Because it can be felt, a grade 1 varicocele counts as a clinical varicocele, so it may be treated in a man with fertility problems and an abnormal semen test when no other cause is found.
Where can I see varicocele grades pictures?
We do not show clinical photos. In words: grades 0 and 1 look normal, grade 2 still looks normal but can be felt as soft cords when standing, and grade 3 can be seen as twisted, bluish veins above the testicle that shrink when lying down. Your doctor can show you your own scan images.
Sources and further reading
- Dubin L, Amelar RD. Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Fertil Steril 1970;21(8):606-9
- Freeman S et al. Ultrasound evaluation of varicoceles: ESUR-SPIWG guidelines and recommendations for detection, classification and grading. Eur Radiol 2020;30:11-25
- Bertolotto M et al. Ultrasound evaluation of varicoceles: systematic literature review and rationale of the ESUR-SPIWG guidelines. J Ultrasound 2020;23(4):487-507
- European Association of Urology — Guidelines on Sexual and Reproductive Health: male infertility (varicocele section)
- MedlinePlus (US National Library of Medicine) — Varicocele
This article is general information, not personal medical advice. Please speak to a doctor about your own symptoms. How we create our content.
