Physical Examination Findings for Left Varicocele
Key Clinical Examination Findings
The diagnosis of varicocele is primarily clinical, performed with the patient in both supine and standing positions during Valsalva maneuver, with a prominent pampiniform plexus being diagnostic. 1, 2
Essential Examination Technique
Position-dependent examination is critical: Evaluate the patient in both supine and standing positions, as varicoceles become more prominent when upright due to gravitational effects 2, 3
Palpation reveals a "bag of worms" sensation: The dilated, tortuous veins of the pampiniform plexus create a characteristic thickening that can be palpated in the scrotum 4
Valsalva maneuver increases prominence: An increase in diameter of the spermatic cord during Valsalva is the key finding that indicates varicocele 1
Grading is based on palpability:
Associated Physical Findings
Testicular size asymmetry: Look for ipsilateral testicular volume reduction, particularly a size difference >2 mL or 20% compared to the contralateral testis 1
Left-sided predominance: While traditionally considered left-sided (approximately 80-90% of cases), bilateral involvement is actually present in up to 80.8% of cases when thoroughly evaluated 5
Reducibility when supine: The varicocele typically decreases or disappears when the patient lies down, distinguishing it from other scrotal masses 2
Critical Red Flags
Right-sided or non-reducible varicocele in elderly men: This warrants immediate evaluation for renal tumor or inferior vena cava obstruction, as it may indicate venous obstruction from an abdominal mass 4
Sudden onset varicocele: New-onset varicocele, particularly in older patients, requires abdominal imaging to exclude malignancy 6, 4
Role of Ultrasound Confirmation
Doppler ultrasound confirms clinical findings: While diagnosis is clinical, scrotal Doppler ultrasound should be performed to confirm varicocele grade and evaluate blood flow patterns, particularly useful in obese patients where examination is difficult 1, 6
Standing position with Valsalva during ultrasound: Mean maximal vein diameter increases to 5.0 mm (grade I), 5.8 mm (grade II), and 6.6 mm (grade III) compared to 2.5 mm in normal testicular units during Valsalva in standing position 1, 3
Do not routinely screen for subclinical varicoceles: Routine ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of subclinical varicoceles does not improve semen parameters or fertility rates 1, 6
Additional Systemic Examination
- Evaluate for signs of underlying pathology: In the context of renal cell carcinoma workup, examine for supraclavicular adenopathy, abdominal mass, lower extremity edema, or subcutaneous nodules, as varicocele can be a presenting sign of renal malignancy 7