Classification of Severe Varicocele
A severe varicocele (grade 3) is defined as a varicocele that is visible through the scrotal skin without palpation and is typically greater than 10 mm in diameter. 1
Varicocele Grading Systems
The most widely accepted clinical grading system for varicoceles includes three grades 2:
- Grade 1: Palpable only during Valsalva maneuver
- Grade 2: Palpable without Valsalva maneuver
- Grade 3: Visible through scrotal skin and palpable without Valsalva maneuver
For gastric varices, severe (large) fundal varices are defined as those ≥10 mm in diameter 3
In ultrasound-based classifications, such as the Sarteschi/Liguori classification (recommended as the most complete scoring system), severe varicoceles correspond to the highest grades and are characterized by visible venous dilatation and reflux 2
Clinical Significance of Severe Varicoceles
Severe (grade 3) varicoceles are associated with worse semen parameters and greater testicular dysfunction compared to lower grades 4
Higher varicocele grade correlates with increased risk of infertility, with varicoceles present in approximately 15% of the normal male population but 35-40% of men presenting with infertility 4, 5
Severe varicoceles show greater improvement in sperm count after surgical repair compared to moderate or mild varicoceles 5
Pathophysiological Impact
The pathophysiology of varicocele involves multiple mechanisms affecting testicular function 4, 5:
- Higher scrotal temperature
- Testicular hypoxia
- Reflux of toxic metabolites
- Increased DNA damage
Severe varicoceles may lead to testicular atrophy with impaired sperm production and decreased Leydig cell function 6
Clinical Implications
The European Association of Urology strongly recommends surgery for varicocele when associated with a persistent small testis (size difference >2 mL or 20%), confirmed on two subsequent visits 6 months apart 4
Treatment of clinical varicoceles may improve surgical sperm retrieval rates among patients with non-obstructive azoospermia, especially for those with hypospermatogenesis 4
After varicocele repair, improvements in semen parameters typically take up to two spermatogenic cycles (approximately 3-6 months) 7, 5
Important Considerations
Not all varicoceles require treatment; only 20% of men with documented varicoceles suffer fertility problems 8, 6
Treatment should be targeted to men with clinical varicoceles and abnormal semen parameters, as treatment of men with normal semen analysis or subclinical varicoceles is not recommended 5
Routine use of ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of these subclinical varicoceles is not associated with improvement in fertility rates 5
Secondary causes such as Nutcracker Syndrome should be considered in atypical presentations of severe varicoceles, especially when hematuria is present 1