Investigations
1st investigations to order
clinical diagnosis
Test
Physical examination is the primary diagnostic test for varicoceles.
With the patient in a standing position, most moderate or large varicoceles are readily apparent by direct visualisation or by palpation of the spermatic cord above the testicle. Examination may reveal the pathognomonic 'bag of worms' appearance.
The Valsalva manoeuvre may be necessary to elicit small varicoceles (grade I/II).
A supine examination is performed to ensure drainage of the varicocele in the recumbent position. A varicocele that does not diminish in the supine position is an indication for further imaging.
Result
presence of varicocele
Investigations to consider
scrotal ultrasound with colour flow Doppler imaging
Test
Used as adjunct to a physical examination to detect varicocele in men with difficult examination: for example, due to small scrotum, or to obesity.
Most accurate means to measure testicular size and make comparison with contralateral testis; can also identify sub-clinical varicoceles.[41] Ultrasound images should be taken with the patient standing, as dilated veins may not be as readily apparent in the supine position.
Typically ordered following clinical diagnosis as considered appropriate; may be of value as an accurate baseline measurement for subsequent serial examinations.
Sub-clinical varicoceles are present in 60% of men attending fertility clinics and 40% of normal men.[42][43]
While ultrasound can be a useful tool, its utility is limited by the lack of standardisation for examination technique, diagnostic criteria, or classification.[29]
Result
presence of varicocele; identification of sub-clinical varicocele
semen analysis
Test
For infertile men with a varicocele, two or three semen analyses are recommended.[31] Obtaining a semen sample in an adolescent may be challenging and must be addressed on an individual basis.
An abnormal sperm concentration and/or abnormal sperm motility may identify patients who are more likely to benefit from surgical correction.[26]
Result
variable; reduced sperm count; impaired sperm motility (<50% motile spermatozoa)
serum FSH (± GnRH stimulation)
Test
Abnormal sperm production in the context of an elevated FSH is consistent with impaired spermatogenesis (due to varicocele and/or other causes). However, elevation of FSH with or without GnRH stimulation test does not always correlate with abnormal semen parameters or fertility.
Of note, FSH levels in the high/normal of the reference range are considered abnormal in men with impaired semen parameters.
Routine use of this test in adolescents is limited.[1]
Result
variable; FSH may be elevated (suggesting testicular dysfunction)
serum testosterone
Test
Reduced testosterone levels suggest impaired steroidogenesis.
Men presenting with low testosterone and related symptoms may also be found to have a varicocele. Varicocele is a potential cause of decreased testosterone production.[30]
Result
variable; may be low
DNA fragmentation index (DFI)
Test
Sperm DNA fragmentation is associated with male infertility.[32] Assessment of the sperm DFI, in combination with conventional semen analysis, may facilitate improved diagnostic accuracy of male infertility.[33]
Furthermore, emerging evidence indicates that varicocele repair could be associated with improvement in DFI and likelihood of pregnancy.[34][35][36][37]
Improvement in sperm parameters is variable, and contingent on patient factors including varicocele grade, age, pre-treatment sperm parameters, and hormone levels.[38] In the presence of multiple potential causes for impaired semen parameters, or in cases of infertility despite normal semen parameters, ancillary testing such as DFI might help decide whether to treat a varicocele.[39]
Result
increased
CT abdomen/pelvis
Test
If a varicocele does not diminish in the supine position, further imaging is considered to rule out abdominal or retroperitoneal mass causing physical obstruction of testicular venous return.
Similarly, a right-sided varicocele alone is rare in adolescents and men and should also raise suspicion of a retroperitoneal or pelvic compressive mass, although a retrospective analysis found that laterality of varicocele was not significantly associated with cancer diagnosis in men.[21][25][26][27]
Result
exclude abdominal, pelvic, or retroperitoneal mass
MRI abdomen/pelvis
Test
If a varicocele does not diminish in the supine position, further imaging is considered to rule out abdominal or retroperitoneal mass causing physical obstruction of testicular venous return.
Similarly, a right-sided varicocele alone is rare in adolescents and men and should also raise suspicion of a retroperitoneal or pelvic compressive mass, although a retrospective analysis found that laterality of varicocele was not significantly associated with cancer diagnosis in men.[21][25][26][27]
Result
exclude abdominal, pelvic, or retroperitoneal mass
retroperitoneal ultrasound
Test
If a varicocele does not diminish in the supine position, further imaging is considered to rule out abdominal or retroperitoneal mass causing physical obstruction of testicular venous return.
Similarly, a right-sided varicocele alone is rare in adolescents and men and should also raise suspicion of a retroperitoneal or pelvic compressive mass, although a retrospective analysis found that laterality of varicocele was not significantly associated with cancer diagnosis in men.[21][25][26][27]
Result
exclude retroperitoneal mass
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