Diagnostic Ultrasound - Abdomen and Pelvis

Varicocele
TERMINOLOGY
Definitions
• Dilatation and tortuosity of pampiniform plexus > 2-3 mm
due to congestion and retrograde flow in internal
spermatic vein
IMAGING
General Features
• Best diagnostic clue
○ Dilated serpiginous veins adjacent to superior pole testis
○ "Flash" of color Doppler with Valsalva
• Location
○ Left (78%), right (6%), bilateral (16%)
○ Can extend along spermatic cord to inferior scrotal sac or
rarely may have intratesticular varicocele
• Size
○ Varicose veins are > 2-3 mm diameter, increase in size
with Valsalva
Ultrasonographic Findings
• Grayscale ultrasound
○ US should be performed in supine and standing positions
– Hypoechoic, tubular structures superior and lateral to
testis
○ ± low-level internal echoes due to slow flow and
formation of red cell rouleaux
○ Scan retroperitoneum for mass
• Color Doppler
○ Detection approaches 100% with color Doppler US
○ Slow flow may be visible only with Valsalva
Other Modality Findings
• Catheter venography demonstrates dilated venous
channels
• Enhancing tubular structures may be seen on CECT or MR
Imaging Recommendations
• Best imaging tool
○ US with color Doppler
• Protocol advice
○ Resting and Valsalva color Doppler
DIFFERENTIAL DIAGNOSIS
Tubular Ectasia/Rete Testis
• Normal variant: Dilated tubules of mediastinum &/or testis
• No flow on color Doppler
Testicular Torsion
• Absent or decreased flow to testis on color Doppler
• Enlarged, hypoechoic testis
Epididymitis
• Enlarged epididymis with increased flow on color Doppler
• Flow does not show change with Valsalva
PATHOLOGY
General Features
• Etiology
○ Primary: Incompetent venous valve near junction of left
renal vein (LRV) and IVC
– Left testicular vein is longer than right, enters LRV at
right angle, sometimes arches over LRV
○ Secondary: Obstruction of LRV by renal or adrenal
tumor, nodes, or rarely SMA compression
• Pathophysiology: Engorged veins have 3 distinct
mechanisms of potential testicular damage
○ Increased heat: Warms blood heats testes
○ Oxidative stress: Reactive oxygen species (ROS)
○ Hemodynamics: ↑ venous pressure ↓ arterial inflow
Staging, Grading, & Classification
• Grading of varicoceles
○ Small varicocele: Palpable only with Valsalva maneuver
○ Moderate varicocele: Palpable with patient standing
○ Large varicocele: Visible through scrotal skin, and
palpable with patient standing
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Most frequent cause of male infertility
○ Vague scrotal discomfort or pressure, primarily when
standing
Demographics
• Age
○ Primary: Idiopathic > 15 years
○ Secondary: < 40 years or elderly
• Epidemiology
○ 10-15% of men in USA have varicoceles
○ Subclinical varicocele in 40-75% of infertile men
Natural History & Prognosis
• Excellent prognosis in treated cases
Treatment
• 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
Image Interpretation Pearls
• Valsalva essential for diagnosis of small varicoceles
• Varicocele diagnosed when vessel > 2 mm during quiet
respiration in supine position
SELECTED REFERENCES
1. Cantoro U et al: Reassessing the role of subclinical varicocele in infertile men
with impaired semen quality: a prospective study. Urology. 85(4):826-30,
2015
2. Kim YS et al: Efficacy of scrotal Doppler ultrasonography with the Valsalva
maneuver, standing position, and resting-Valsalva ratio for varicocele
diagnosis. Korean J Urol. 56(2):144-9, 2015
3. Karami M et al: Determination of the best position and site for color Doppler
ultrasonographic evaluation of the testicular vein to define the clinical
grades of varicocele ultrasonographically. Adv Biomed Res. 3:17, 2014
Diagnoses: Scrotum
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