This document discusses testicular varicoceles, which are abnormal dilations of the veins within the pampiniform plexus that surrounds the testicles. Varicoceles are found in approximately 15% of men and can cause scrotal pain or swelling. Ultrasound is the most common imaging method used to diagnose varicoceles by identifying dilated veins in the pampiniform plexus that enlarge further with maneuvers like Valsalva. Treatment options include percutaneous embolization to occlude the spermatic vein by catheterization or surgical ligation of the vein through sub-inguinal, inguinal, or retroperitoneal approaches.

1. Testicular varicoceles
Prepared by :- Dr.Kucha

2. • 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.

3. • 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.

4. 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

5. 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.

6. 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.

7. Figure 1 (a) Grey scale ultrasound demonstrates large
varicocele surrounding the right testes.

8. (b) Coronal
gadolinium-enhanced coronal fast low angle shot
(FLASH) MRI image demonstrates large right renal mass
with ipsilateral varices.

9. Imaging techniques used in evaluating
testicular varicoceles
Imaging method Diagnostic criteria
Ultrasound 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
diameter
Colour 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)

10. 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
vein
MRI Gadolinium-enhanced imaging useful. Delayed imaging in
venous phase identifies mass of dilated vessels and prominence
of the pampiniform plexus
Scintigraphy Static images show intra-scrotal accumulation of the labelled
(technetium- red cells. Supine and erect
99mlabelled imaging is obtained. Reflux may be shown on dynamic images
red blood cells)

11. • 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.

12. (a) There is a varicocele on the left side of
the pampiniform plexus.

13. (b) After Valsalva manoeuvre there is marked engorgement and prominence
of the varicocele.Initially the patient is in the supine position and
then erect. Valsalva is attempted in both.

15. • 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.

16. • 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

19. • 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

22. • 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

23. • 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

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