World Journal of Urology

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World Journal of Urology

World Journal of Urology

    ? 2004


    Topic Paper

    Color Doppler ultrasound investigation of


    1, 2 111Giovanni Liguori, Carlo Trombetta, Giulio Garaffa, Stefano Bucci, 111Ignazio Gattuccio, Leonardo Salamè and Emanuele Belgrano

    (1) Department of Urology, University of Trieste, Triest, Italy

    (2) Via Sticotti 2, 34123 Triest, Italy

    Giovanni Liguori Email:

    Phone: +39-40-3994575

    Fax: +39-40-3994895

    Received: 28 April 2004 Accepted: 28 April 2004 Published online: 18 August 2004

    Abstract Varicocele, whose association with male infertility has been clearly documented in the literature, is a common finding in adolescents and adult men, being diagnosed in 2040%

    of infertile patients. A correct and early diagnosis of this affliction is of great importance because, in most cases, a timely correction, usually performed using percutaneous sclerotherapy, leads to an improvement in semen quality. Currently, physical examination in a warm room is the mainstay of diagnosis, but this is affected by a low sensibility and specificity, especially in cases of low grade varicocele. Colour Doppler ultrasound (CDU) is a new, reliable and non-invasive diagnostic method for the evaluation of varicocele testes which allows the detection of even subclinical varicocele thanks to its capacity for measuring the size of the pampiniformis plexus and blood flow parameters of the spermatic veins. At present, there is a lack of completely standardised diagnostic criteria, but when this problem is solved, clinical examination and CDU will certainly become the gold standard in the investigation

    of varicocele.

    Keywords Varicocele - Infertility - Color Doppler - Ultrasound


    Varicocele, defined as an abnormal venous dilatation of the pampiniformis plexus, is a common finding, having been reported in approximately 15% of adolescents and in 1015%

    of adult men [13]. The association between male subfertility and clinical varicocele has been well documented, with varicocele usually being diagnosed in 2040% of infertile men [4, 14,

    17]. This affliction is actually considered the most common cause of male infertility, even

    though the mechanisms responsible for infertility are still unclear. However, the presence of varicocele does not necessary imply infertility; in fact 80% of patients with varicocele present with normal semen parameters.

    In the case of infertility, only the timely correction of a varicocele can lead to an improvement in the quality of the semen. This fact, pointed out for the first time in 1955, has subsequently been widely confirmed in literature [5, 7, 10, 15].

    Colour Doppler ultrasound (CDU) has the ability to measuring the size of the pampiniformis plexus and blood flow parameters of the spermatic vein. However, the reliability of this technique in detecting varicoceles was controversial and the diagnostic criteria remained poorly defined for many years.

    The use of CDU for the diagnosis of varicocele has been widely evaluated in many studies in recent years [2, 3, 6, 8, 12, 16, 18, 19] .


    The ultrasound study of the scrotum should be performed with high frequency linear probes and with devices able to evaluate blood flux. Blood vessels are first studied in a grey scale and then with the colour Doppler and the pulse Doppler. For the correct detection of fluxes, CDU must be calibrated to detect a slow flow (7.5 kHz).

    The evaluation should be performed in the supine and then the upright positions, with and without a Valsalvas manoeuvre, in order to obtain a complete evaluation of the fluxes in the seminal cord veins.

    A prolonged venous flow augmentation or reflux, usually evidenced by a venous rush during Valsalvas maneuver, confirms the diagnosis. This must be differentiated from the mild and transient flow augmentation seen with a Valsalvas maneuver in some normal men. In

    addition, active cremasteric musculature can make the exact placement of the US probe difficult.

    A varicocele detected by real-time US appears as a hollow, tubular structure that becomes larger during Valsalvas maneuver (Fig. 1).

     Fig. 1 B mode in real time. The diameter of the vein is >3 mm which is clearly evident

Diagnostic criteria

    The first part of the examination is the B-mode evaluation which allows a demonstration of the presence of enlarged venous structures. Different authors use different criteria for defining a varicocele detected ultrasonographically. The diagnosis of varicocele can be made in cases of the detection of vessels larger than 3 mm; conversely Gonda et al. reported that ultrasound has a 95% sensitivity for the detection of a varicocele, using a 2 mm cut off for vein diameter [9]. However other studies suggest that there is no threshold value for the diagnosis of intratesticular varicocele because vascular structures with retrograde flow on CDU may be smaller than 2 mm in diameter [1]. Therefore, a diagnosis based only on the diameter of the

    vessels is characterised by a high number of false positives and negatives. Moreover, this variability makes it difficult to compare the results of diagnostic modalities and treatments. In our opinion, CDU imaging is now the gold standard for the diagnosis of varicocele. Prolonged flow augmentation, depicted on real time imaging as lightened hues within a colored flow, confirms the reversal of flow that is characteristic of a varicocele. Unfortunately, as with most ultrasound studies, CDU imaging is highly operator dependent.

    For us, in order to make a correct diagnosis of varicocele it is necessary to detect a prolonged reflux that must be longer than 2 s. Other studies establish a threshold value of 1 s to distinguish between physiological reflux and varicocele. For this reason, it is important to complete the examination with pulsed Doppler to perceive the sound of the reflux and to

    evaluate its length and velocity.

    In accordance with Sarteschi [16], varicocele can be divided into five grades according to the

    characteristics of the reflux and its length, and to changes during Valsalvas manoeuvre.

CDU classification of varicocele

1. Grade 1 is characterised by the detection of a prolonged reflux in vessels in the inguinal channel only during Valsalvas

    manoeuvre, while scrotal varicosity is not evident in the previous grey-scale study (Fig. 2).

    Fig. 2 Grade 1. A prolonged reflux of vessels in the inguinal channel only during Valsalvas manoeuvre is evident

    2. Grade 2 is characterized by a small posterior varicosity that reaches the superior pole of the testis and whose diameter increases

    after Valsalvas manoeuvre. The CDU evaluation clearly demonstrates the presence of a venous reflux in the supratesticular

    region only during Valsalvas manoeuvre (Fig. 3).

    Fig. 3 Grade 2. A venous reflux in the supratesticular region is present only during Valsalvas manoeuvre

3. Grade 3 is characterised by vessels that appear enlarged to the inferior pole of the testis when the patient is evaluated in a

    standing position, while no ectasia is detected if the examination is performed in a supine position. CDU demonstrates a clear

    reflux only under Valsalvas manoeuvre (Fig. 4).

    Fig. 4 Grade 3. A colour Doppler ultrasound (CDU) study demonstrates a clear reflux only under Valsalvas manoeuvre

    4. Grade 4 is diagnosed if vessels appear enlarged, even if the patient is studied in a supine position; dilatation increases in an

    upright position and during Valsalvas manoeuvre. Enhancement of the venous reflux after Valsalvas manoeuvre is the criteria

    that allows the distinction between this grade from the previous and the next one. Hypotrophy of the testis is common at this

    stage (Fig. 5).

Fig. 5 Grade 4. a Venous reflux is evident in the basal condition, and b increases during Valsalvas manoeuvre

5. Grade 5 is characterised by an evident venous ectasia even in an upright position. CDU demonstrates the presence of an

important basal venous reflux that does not increase after Valsalvas manoeuvre (Fig. 6).

    Fig. 6 Grade 5. a A CDU study demonstrates a significant reflux. b The reflux does not increase after Valsalvas manoeuvre

Diagnosis of bilateral varicocele

    After the detection of left varicocele, it is necessary to study the contralateral testis in order to detect the eventual coexistence of contralateral venous ectasia and blood reflux. In case of bilateral ectasia, it is mandatory to distinguish, by the use of CDU of the right inguinal channel, between false and real bilateral varicocele because these two situations require two different types of treatment.

    False bilateral varicocele is characterised by the absence of reflux in the inguinal channel and the venous ectasia is fed by the contralateral varicosity of the pampiniformis plexus through the communicant transsectal vessels. In this case, bilateral surgical treatment is not required and the correction of the left varicocele usually leads to the regression of the right ectasia. Conversely, in real bilateral varicocele the venous ectasia is due to right gonadic vein reflux, and therefore a diagnosis of bilateral varicocele can be easily made in the case of CDU detection of bilateral inguinal channel reflux. In these cases, a bilateral treatment must be performed.


    Although a physical examination is currently the standard diagnostic method for the diagnosis of varicocele, it is subjective and may have significant inter-physician variability. It is also

    limited in its capacity to detect blood flow changes. In fact hyperactivity of the dartos muscle or contraction of the cremaster muscle induced by palpation or Valsalvas manoeuvre may

    mimic or mask testicular venous distension, making it difficult to distinguish these structures from true testicular venous distension, especially in cases of low grade clinical varicocele [11].

    This limit is of great importance because subclinical varicoceles may play an important role in infertility, and even a small varicocele, detectable only by radiological imaging, may have a significant effect on spermatogenesis.

    Varicocele testis is a perfect condition to be evaluated by CDU. Doppler scanning is a much more reliable and reproducible technique and a diagnostic tool which could also be valuable in the operating theatre. We suggest that a clinical examination and CDU could be the gold standard in the investigation of varicocele because CDU is non-invasive, involves no ionizing radiation and is well-tolerated by the patient.


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