Diagnostic Ultrasound - Abdomen and Pelvis

Varicocele
Diagnoses: Scrotum
TERMINOLOGY
• Dilatation of pampiniform plexus > 2-3 mm due to
congestion and retrograde flow in internal spermatic vein
IMAGING
• Dilated serpiginous veins at superior pole testis
• "Flash" of color Doppler with Valsalva
• Left (78%), right (6%), bilateral (16%)
• Varicose veins are > 2-3 mm diameter, increase in size with
Valsalva
PATHOLOGY
• Primary: Incompetent venous valve near junction of left
renal vein (LRV) and IVC
• Secondary: Obstruction of LRV by renal or adrenal tumor,
nodes or rarely SMA compression
CLINICAL ISSUES
• Most frequent cause of male infertility
KEY FACTS
• Vague scrotal discomfort or pressure, primarily when
standing
• 10-15% of men in USA have varicoceles
• Subclinical varicocele in 40-75% of infertile men
• Catheter embolization, surgical treatment, or sclerotherapy
if symptomatic
• Emerging research suggests even subclinical varicoceles
should be treated
DIAGNOSTIC CHECKLIST
• Consider left renal vein occlusion by tumor in elderly male
patient presenting with recent onset varicocele
• Valsalva essential for diagnosis of small varicoceles
• Varicocele diagnosed when vessel > 2 mm during quiet
respiration in supine position
(Left) Graphic shows dilated,
tortuous varicose veins of the
pampiniform plexus ſt in the
spermatic cord and along the
posterosuperior aspect of the
testis st. (Right) Oblique
grayscale ultrasound through
cord, in supine position with
normal respiration, shows a
dilated, tortuous principal vein
st in pampiniform plexus
measuring 7.5 mm in caliber.
(Left) Longitudinal color
Doppler ultrasound shows
multiple serpiginous, dilated
veins st in the pampiniform
plexus of the cord, along the
posterosuperior aspect of
testis in supine position during
normal respiration. (Right)
Longitudinal color Doppler
ultrasound in the same patient
shows flow st in these dilated
veins during Valsalva,
indicative of moderate
varicocele. Blood flow in the
varicocele is slow and may be
detected only with low
Doppler settings.
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