Ultrasound of Varicocele

In this radiology lecture, we review the ultrasound appearance of scrotal varicocele with three unique cases.

Key teaching points include:

Varicocele is abnormal dilatation of pampiniform venous plexus = Peritesticular veins.
Seen in up to 15% of adult and adolescent males.
Caused by incompetent or absent testicular vein valves.
Upper limit of normal for scrotal vein caliber = 2 mm, varicocele when greater than 2-3 mm.
Flow in varicocele usually too slow to detect with color Doppler and is typically better seen with Valsalva or with standing position.
85% left sided, 15% bilateral: Left testicular vein drains into left renal vein at 90-degree angle, and superior mesenteric artery compresses left renal vein = Increased pressure and venous backflow. Right vein drains into IVC at acute angle.
Symptoms: Scrotal mass, pain, infertility/subfertility.
Low grade: Reflux only seen with Valsalva, inguinal canal/supratesticular location, vessels enlarged only in standing position.
High grade: Reflux seen at rest, infratesticular location, vessels enlarged in supine position.
Solitary right varicocele raises concern for compression of the right testicular vein from a retroperitoneal mass.
Ultrasound of upper abdomen should be considered when an isolated right-sided varicocele or asymmetrically large right-sided varicocele found.
However, most patients typically present with additional signs and symptoms of malignancy: “No patient in our cohort was found to have an unsuspected malignancy for which isolated right-sided varicocele was the only presenting sign.”*