Tests
1st tests to order
clinical diagnosis
Test
Physical exam is the primary diagnostic test for varicoceles.
With the patient in a standing position, most moderate or large varicoceles are readily apparent by direct visualization or by palpation of the spermatic cord above the testicle. Exam may reveal the pathognomonic "bag of worms" appearance.
The Valsalva maneuver may be necessary to elicit small varicoceles (grade I/II).
A supine exam 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
Tests to consider
scrotal ultrasound with color flow Doppler imaging
Test
Used as adjunct to a physical exam to detect varicocele in men with difficult exam: 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 subclinical varicoceles.[40] 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 exams.
Subclinical varicoceles are present in 60% of men attending fertility clinics and 40% of normal men.[41][42]
While ultrasound can be a useful tool, its utility is limited by the lack of standardization for exam technique, diagnostic criteria, or classification.[28]
Result
presence of varicocele; identification of subclinical varicocele
semen analysis
Test
For infertile men with a varicocele, two or three semen analyses are recommended.[29]
Obtaining a semen sample in an adolescent may be challenging and must be addressed on an individual basis.[23]
Abnormal sperm concentration and/or abnormal sperm motility may help identify men who are more likely to benefit from surgical correction.[25]
Serial semen analyses every 1-2 years may be used to monitor for signs of impaired testicular function in men with varicocele who do not currently require treatment.[29]
Result
variable; reduced sperm count; impaired sperm motility (<50% motile spermatozoa)
serum follicle-stimulating hormone (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.
FSH levels in the high/normal of the reference range are considered abnormal in men with impaired semen parameters.
FSH testing is not carried out routinely in adolescents; there is a lack of consensus regarding its use.[23]
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)
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.
A right-sided varicocele alone is rare in adolescents and men and should raise suspicion of a retroperitoneal or pelvic compressive mass (although this is rare).[24]
In adolescents, imaging is considered, such as CT or MRI scan of the abdomen and pelvis, or retroperitoneal ultrasound.[24]
In adults, an isolated large (grade 3) right-sided varicocele warrants further evaluation with the appropriate imaging (CT or MRI of abdomen and pelvis, or retroperitoneal ultrasound). Imaging is not routinely recommended for a small or moderate right-sided varicocele.[25] A retrospective analysis found that laterality of varicocele was not significantly associated with cancer diagnosis in men.[26]
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.
A right-sided varicocele alone is rare in adolescents and men and should raise suspicion of a retroperitoneal or pelvic compressive mass (although this is rare).[24]
In adolescents, imaging is considered, such as CT or MRI scan of the abdomen and pelvis, or retroperitoneal ultrasound.[24]
In adults, an isolated large (grade 3) right-sided varicocele warrants further evaluation with the appropriate imaging (CT or MRI of abdomen and pelvis, or retroperitoneal ultrasound). Imaging is not routinely recommended for a small or moderate right-sided varicocele.[25] A retrospective analysis found that laterality of varicocele was not significantly associated with cancer diagnosis in men.[26]
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.
A right-sided varicocele alone is rare in adolescents and men and should raise suspicion of a retroperitoneal or pelvic compressive mass (although this is rare).[24]
In adolescents, imaging is considered, such as CT or MRI scan of the abdomen and pelvis, or retroperitoneal ultrasound.[24]
In adults, an isolated large (grade 3) right-sided varicocele warrants further evaluation with the appropriate imaging (CT or MRI of abdomen and pelvis, or retroperitoneal ultrasound). Imaging is not routinely recommended for a small or moderate right-sided varicocele.[25] A retrospective analysis found that laterality of varicocele was not significantly associated with cancer diagnosis in men.[26]
Result
exclude retroperitoneal mass
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