Varicocele Workup

Updated: Jan 02, 2019
  • Author: Wesley M White, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Workup

Laboratory Studies

When the clinical examination findings are equivocal, high-resolution color-flow Doppler ultrasonography is the diagnostic method of choice. The Male Infertility Best Practice Policy Committee of the American Urological Society recommends that imaging studies are not indicated for the standard evaluation unless the physical examination provides inconclusive findings. [10]

If a patient has sudden onset of a varicocele, a single right-sided varicocele, or any varicocele that is not reducible in the supine position, consider possible retroperitoneal pathology (eg, renal cell carcinoma) as the cause of spermatic vein compression. Investigate further with appropriate ultrasonography or CT scanning before repairing the varicocele.

Although varicocele diagnosis may be assisted with numerous methods (eg, venography, radionuclide angiography, thermography, ultrasonography), the current standard of care is high-resolution color-flow Doppler ultrasonography. High-resolution real-time scrotal ultrasonography using a 7- to 10-MHz probe defines a varicocele as a hollow tubular structure that grows following a Valsalva maneuver.

Color-flow Doppler ultrasonography defines the anatomic and physiologic aspects of varicoceles by using real-time ultrasonography and pulsed Doppler in the same scan. The color of the signal identifies the blood flow and direction within the varicocele. The characteristic reverse flow of varicoceles is confirmed by prolonged flow augmentation within a colored flow area; the flow changes color (ie, reverses) on real-time imaging.

Although the exact size definition is controversial, most surgeons consider a varicocele to be a vein 3 mm in diameter or larger while the patient is at rest. McClure et al define a varicocele as the presence of 3 or more veins, with 1 having a minimum resting diameter of 3 mm or an increase in venous diameter with the Valsalva maneuver. [18] Because other surgeons use 2-3 mm as a cutoff, comparing results of these ultrasound-based varicocelectomy studies is difficult.

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Imaging Studies

Ultrasonography, particularly Doppler ultrasonography, allows accurate diagnosis of varicoceles. Computed tomography can demonstrate varicoceles, but exposure to radiation is a disadvantage, and the diagnostic role of magnetic resonance imaging (MRI) has not been established. Venography is usually reserved for use in patients undergoing occlusive therapy, for mapping of the venous anatomy.

Tsili et al describe the use of 1.5 T diffusion tensor imaging (DTI) MRI as an adjunct tool for the diagnosis of varicocele. In their study, fractional anisotropy (FA) was significantly lower in the testes with varicocele in 16 infertile men, compared with 14 age-matched controls. A cut-off of FA 0.08 had 88% sensitivity, 93.5% specificity, 91.6% positive predictive value, and 90.6% negative predictive value for the diagnosis of varicocele. [19]  Other pilot studies of diffusion-weighted imaging MRI have reported that decreased apparent diffusion coefficient (ADC) values in the testicles of patients with varicocele correlate with abnormal semen parameters. [20, 21]

For complete discussion of this topic, see Varicocele Imaging.

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