• A varicocele is an abnormal degree of venous dilatation in the pampiniform plexus.• It affects approximately 15% of men. It can present with scrotal pain and swelling, or during the investigation of male sub-fertility.• Nowadays most are detected incidentally in patients undergoing scrotal ultrasound for other reasons and remain clinically silent.
• The aetiology of varicoceles is unclear.• Idiopathic varicoceles are more common on the left side where the left spermatic vein enters perpendicular to the left renal vein. The right spermatic vein enters obliquely into the inferior vena cava and this appears to have some protective effect on the right side.• Retrograde ﬂow into the internal spermatic vein results in dilatation and tortuosity of the pampiniform plexus.
Diagnosis Clinical• Varicoceles may be symptomatic with pain and swelling.• A Valsalva manoeuvre (expiration against a closed glottis) is an important part of the clinical examination as this causes distension of the pampiniform plexus allowing greater visualization. Varicoceles greater than 3–4 mm in diameter are usually clinically apparent.• A large varicocele is often described as a bag of worms surrounding the testis
clinical grading system for palpable varicoceles.• Grade 1 varicoceles are considered to be those palpable only during a Valsalva manoeuvre.• Grade 2 varicoceles are palpable without the Valsalva manoeuvre.• Grade 3 varicoceles are visible on examination before palpation.
Imaging• Ultrasound is now the most frequently used method and a high-frequency transducer of at least 7 MHz should be used. The features on grey scale ultrasound include a prominence of at least two to three veins of the pampiniform plexus, of which one should have a diameter greater than 2–3 mm in a supine position.
Figure 1 (a) Grey scale ultrasound demonstrates large varicocele surrounding the right testes.
(b) Coronal gadolinium-enhanced coronal fast low angle shot(FLASH) MRI image demonstrates large right renal mass with ipsilateral varices.
Imaging techniques used in evaluating testicular varicocelesImaging method Diagnostic criteriaUltrasound Tortuous anechoic tubular structures adjacent to the testis. R2 prominent veins in pampiniform plexus. Expand with Valsalva manoeuvre and upright position with at least one > 2–3 mm in diameterColour Doppler Reﬂux in the spermatic vein, which increases with Valsalva manoeuvre, may be identiﬁed. Doppler sonography can be used to grade venous reﬂux as static (grade I), intermittent (grade II), or continuous (grade III)
Venography Enlargement of internal spermatic vein with reﬂux into the abdominal, inguinal, scrotal or pelvic portions of the spermatic vein. Venous collateralization present. Incompetent spermatic veinMRI Gadolinium-enhanced imaging useful. Delayed imaging in venous phase identiﬁes mass of dilated vessels and prominence of the pampiniform plexusScintigraphy Static images show intra-scrotal accumulation of the labelled(technetium- red cells. Supine and erect99mlabelled imaging is obtained. Reﬂux may be shown on dynamic imagesred blood cells)
• Colour Doppler has been shown to improve diagnostic ability by the detection of reverse ﬂow in the incompetent vein. The reﬂux is quantiﬁed as permanent, which is signiﬁcant for a varicocele; intermittent; or brief, which is physiological. Intermittent reﬂux is an area of debate and is usually insigniﬁcant if there is no palpable varicocele.
(a) There is a varicocele on the left side ofthe pampiniform plexus.
(b) After Valsalva manoeuvre there is marked engorgement and prominenceof the varicocele.Initially the patient is in the supine position andthen erect. Valsalva is attempted in both.
• venography is still considered to be the gold standard, it is time consuming and invasive.• If a varicocele is present, the internal spermatic vein will be enlarged and there will be reﬂux into the abdominal, inguinal, scrotal or pelvic portions of the spermatic vein. There will also be venous collateralization and anastomotic channels.
• The degree of reﬂux on venography from 0 to 5.• Grade 0 was no reﬂux, grade 1 to 5 represented reﬂux into the upper lumbar, lower lumbar, upper pelvic, lower pelvic or inguinal portions of the spermatic veins, respectively
• Imaging with other techniques, such as magnetic resonance imaging (MRI) or computed tomography (CT), is only occasionally required, for example, to evaluate the presence of obstructing masses particularly on the right side.• When conventional venography is contraindicated (history of anaphylaxis, etc), magnetic resonance venography (MRV) is a suitable alternative (Fig. 6).• Magnetic resonance angiography has been used for the assessment of recurrent varicoceles
• the choice is between surgical treatment and radiological treatment.• Where there is a trained radiologist, percutaneous embolization should be the ﬁrst- line therapy, with surgery reserved for the small proportion of patients who have failed catheterization
• Percutaneous embolization involves selective catheterization of the spermatic vein and subsequent occlusion with a sclerosing agent or a solid embolization coil.• With surgery, three common techniques are employed. These are sub-inguinal ligation, inguinal ligation and retroperitoneal ligation, with the latter being the most frequently practiced