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.

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.

Treatment & Management

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Çekiç B, Kiliç KK, Toslak IE, Şükun A, Sağlik S, Savaş M, et al. Correlation Between Semen Analysis Parameters and Diffusion-Weighted Magnetic Resonance Imaging of the Testicles in Patients With Varicocele: A Pilot Study. J Comput Assist Tomogr. 2018 May/Jun. 42 (3):423-428. [QxMD MEDLINE Link].
Emad-Eldin S, Salim AMA, Wahba MH, Elahwany AT, Abdelaziz O. The use of diffusion-weighted MR imaging in the functional assessment of the testes of patients with clinical varicocele. Andrologia. 2018 Nov 20. e13197. [QxMD MEDLINE Link].
Arab D, Doustmohammadi H, Ardestani Zadeh A. Dietary supplements in the management of varicocele-induced infertility: A review of potential mechanisms. Andrologia. 2021 Feb. 53 (1):e13879. [QxMD MEDLINE Link].
Ioannidou PG, Papanikolaou DA, Bosdou JK, Goulis DG, Lambropoulos AF, Grimbizis GF, et al. Improvement in sperm quality by oral antioxidant supplementation in infertile men with varicocele who have not undergone surgical repair: Systematic review and meta-analysis. Andrologia. 2022 Nov. 54 (10):e14533. [QxMD MEDLINE Link].
Bernie HL, Goldstein M. Varicocele Repair Versus Testosterone Therapy for Older Hypogonadal Men with Clinical Varicocele and Low Testosterone. Eur Urol Focus. 2018 Apr. 4 (3):314-316. [QxMD MEDLINE Link].
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Media Gallery

A large varicocele is seen through the scrotal skin. In a patient with a varicocele, the dilated vessels of the pampiniform plexus are easily appreciated within the scrotum.
Incision for an inguinal approach to varicocele repair.

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Author

Wesley M White, MD Chair, Associate Professor, Director of Laparoscopic and Robotic Urologic Surgery, Department of Urology, University of Tennessee Graduate School of Medicine

Wesley M White, MD is a member of the following medical societies: American Urological Association, Endourological Society, Society of Academic Urologists, Society of Urologic Oncology, Southeastern Section of the American Urological Association (AUA), Tennessee Medical Association, Tennessee Urological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Joe D Mobley, III, MD, MPH Urologist, Kentucky Lake Urology Clinic

Joe D Mobley, III, MD, MPH is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Endourological Society, Tennessee Medical Association

Disclosure: Nothing to disclose.

Edward David Kim, MD, FACS Professor of Urology, Department of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American Society for Reproductive Medicine, American Urological Association, Sexual Medicine Society of North America, Society for Male Reproduction and Urology, Society for the Study of Male Reproduction, Tennessee Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Mark Jeffrey Noble, MD Consulting Staff, Urologic Institute, Cleveland Clinic Foundation

Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, The Scientific Research Honor Society, Society of University Urologists, SWOG

Disclosure: Nothing to disclose.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoscopic and Robotic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Endourological Society Board of Directors; President Elect North Central Section of the American Urological Association<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical.

Additional Contributors

Gamal Mostafa Ghoniem, MD, FACS Professor and Vice Chair of Urology, Chief, Division of Female Urology, Pelvic Reconstructive Surgery, and Voiding Dysfunction, Department of Urology, University of California, Irvine, School of Medicine

Gamal Mostafa Ghoniem, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urogynecologic Society, American Urological Association, International Continence Society, International Urogynaecology Association, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Astellas<br/>Received research grant from: Uroplasty/Cogentix, Astellas, Allergen.

Varicocele Workup

Laboratory Studies

Imaging Studies

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