From the Guidelines
Diagnosis of varicocele primarily involves physical examination, with ultrasound with color Doppler as the preferred imaging modality when physical examination is inconclusive. The physical examination should be performed with the patient standing in a warm room, inspecting and palpating the scrotum for a "bag of worms" sensation, and using the Valsalva maneuver to enhance detection 1. Varicoceles are graded on a scale: grade 1 (palpable only during Valsalva), grade 2 (palpable without Valsalva), and grade 3 (visible through the scrotal skin).
Some key points to consider in the diagnosis of varicocele include:
- Most varicoceles occur on the left side due to anatomical factors, including the left testicular vein's perpendicular entry into the renal vein 1.
- A sudden onset right-sided or bilateral varicocele in an older man warrants investigation for potential abdominal or pelvic masses that might be causing venous obstruction 1.
- Ultrasound with color Doppler can detect veins larger than 3mm in diameter and retrograde blood flow, making it a valuable tool in the diagnosis of subclinical varicoceles 1.
- Routine use of ultrasonography to identify clinical (non-palpable) varicocele is discouraged, as treatment of these varicoceles is not helpful 1.
In terms of imaging,
- Scrotal ultrasound can be used before repair to confirm the presence of varicocele and also following correction to determine procedural success, in the context of shared decision-making with the patient 1.
- Clinicians should not perform transrectal ultrasonography (TRUS) or pelvic MRI as part of the initial evaluation of the infertile male, unless there is a suspicion of ejaculatory duct obstruction (EDO) 1.
Overall, the diagnosis of varicocele should be approached with a focus on physical examination and selective use of imaging modalities, taking into account the patient's individual characteristics and clinical presentation 1.
From the Research
Diagnosis of Varicocele
- Varicocele is a common treatable cause of testicular pain, male infertility, and Leydig cell dysfunction 2
- Scrotal ultrasonography has become the modality of choice in the diagnosis and post-treatment follow-up of varicocele, enabling accurate diagnosis through visualization of dilated veins and reflux into the pampiniform plexus 2
- The pathophysiology of varicocele in testicular dysfunction remains unclear, but numerous studies have established significant improvement in seminal parameters and pregnancy rates after varicocele repair 2
Treatment Options
- Interventional therapy is a minimally invasive effective treatment option for primary and salvage varicocele repair 2
- Percutaneous embolization treatment and laparoscopic varicocelectomy are two minimally invasive treatment modalities for varicoceles, with technical success rates of 95% and 100%, respectively 3
- Embolization treatment has been associated with a lower complication rate than laparoscopic repair, and offers treatment advantages compared with laparoscopic repair in patients with varicoceles 3, 4
- Microsurgical approach is recommended for bilateral varicoceles, where technical failure rates are expected to be less than 5% 4
- Men with unilateral left-sided varicoceles can be offered both embolization and microsurgical options, as they have similar failure rates 4
Current Standards and Recommendations
- Percutaneous embolisation is an effective, minimally invasive means of treating varicoceles, with refined and expanded techniques and tools currently offering excellent outcomes 5
- CIRSE Standards of Practice documents recommend a reasonable approach to, and best practices for, the performance of percutaneous varicocele embolisation, including indications for treatment, performance of each modality, and advantages and limitations 5