History and Physical Examination
The vast majority of adolescents with varicoceles are asymptomatic. The diagnosis is made by carefully palpating the scrotum during a thorough upright physical examination. The patient is examined in the standing position, and the scrotum is visually inspected for distended veins, which can usually be seen on the lateral aspect of the scrotum. The testes, spermatic cord, and scrotum are palpated, and testicular size is assessed with an orchidometer. A small varicocele may feel like a thickened spermatic cord; a larger one has been said to feel like a bag of worms.
The physician should then ask the patient to perform a Valsalva maneuver, which distends the veins of the pampiniform plexus and accentuates physical findings. This is a necessary adjunct, albeit one that is often omitted in the primary care setting, for helping the clinician detect subtle changes in the pampiniform plexus that can facilitate the diagnosis of a varicocele. [12]
Next, examine the patient in a supine position. The venous dilation of the varicocele should diminish. Consider an obstructive etiology if this does not occur.
The testes of a normal patient should be symmetrical in size and consistency. The orchidometer can be a reliable method of assessing testicular size, with good interobserver variability [13] ; however, compared with ultrasonography (US), it may be inaccurate in distinguishing a testis volume differential of less than 50%. [14]
Two formulas are used to calculate testicular volume on the basis of dimensions obtained via US: the Lambert formula and the volume-of-rotational-ellipsoid formula. The Lambert formula is as follows:
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Testicular volume = Length × width × depth × 0.71
Two variations exist for the volume-of-rotational-ellipsoid formula:
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Testicular volume = Length × width × depth × 0.52
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Testicular volume = Length × width 2 × 0.52
Hsieh et al studied the reliability of these formulas and found that the Lambert formula was more accurate than either volume-of-rotational-ellipsoid formula and more precise than the second of the two volume-of-rotational-ellipsoid formulas. [15]
A size difference of more than 3 cm3 is considered significant. The average volume of the male testis is 23 ± 3 cm3, and standardized tables show the reference ranges for appropriate testis volume at different stages of development (see Table 1 below). [16]
Table 1. Average Male Testis Volume at Different Stages of Development, as Determined by Orchidometer [16] (Open Table in a new window)
Tanner Stage |
Left Testis |
Right Testis |
1 |
4.76 ± 2.76 cm3 |
5.20 ± 3.86 cm3 |
2 |
6.40 ± 3.16 cm3 |
7.08 ± 3.89 cm3 |
3 |
14.58 ± 6.54 cm3 |
14.77 ± 6.1 cm3 |
4 |
19.80 ± 6.17 cm3 |
20.45 ± 6.79 cm3 |
5 |
28.31 ± 8.52 cm3 |
30.25 ± 9.64 cm3 |
Other presentations of varicoceles include symptoms of acute or chronic scrotal discomfort, differing testicular sizes without a palpable varicocele on recumbent physical examination, and incidental finding on scrotal US.
Classification
Varicoceles are graded on the basis of physical examination findings and are classified as described by Dubin and Amelar [17] :
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Grade 0 - Subclinical varicocele; cannot be detected during physical examination; generally identified with US or venography
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Grade 1 - Detected with palpation with difficulty (< 1 cm); increase in size with Valsalva maneuver
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Grade 2 - Easily detected without Valsalva maneuver (1-2 cm)
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Grade 3 - Detected visually at a distance (>2 cm)
Multiple investigators have directly correlated the degree of testicular atrophy with varicocele grade. Steeno noted that testis volume was reduced by 81% in patients with grade 3 varicoceles and by 34% in patients with grade 2 varicoceles. [18] No patients with grade 1 varicoceles were noted to have testicular atrophy.
Lyon et al reported that 77% of adolescent boys with easily palpable varicoceles had testis growth arrest, further suggesting that larger varicoceles are more likely to be associated with growth arrest. [19] Some evidence shows that larger (grade 3) varicoceles may also place the contralateral right testis at risk for atrophy.
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Laparoscopic varicocelectomy.
Tables
Tanner Stage |
Left Testis |
Right Testis |
1 |
4.76 ± 2.76 cm3 |
5.20 ± 3.86 cm3 |
2 |
6.40 ± 3.16 cm3 |
7.08 ± 3.89 cm3 |
3 |
14.58 ± 6.54 cm3 |
14.77 ± 6.1 cm3 |
4 |
19.80 ± 6.17 cm3 |
20.45 ± 6.79 cm3 |
5 |
28.31 ± 8.52 cm3 |
30.25 ± 9.64 cm3 |
Technique |
Hydrocele |
Recurrence or Failure |
Open inguinal/sublingual |
3-9% |
15% average |
Microscopic inguinal/sublingual |
< 1% |
1-3% |
Retroperitoneal mass ligation |
7.2% |
2% |
Retroperitoneal artery sparing |
< 7.2% |
11% |
Laparoscopic |
Similar to open |
Similar to open |
Embolization |
None |
10-25% |
