Clinical Radiology (2005) 60, 1248–1255

REVIEW

Testicular varicoceles
P. Beddy, T. Geoghegan, R.F. Browne, W.C. Torreggiani*

Department of Radiology, The Adelaide and Meath Hospital, Tallaght, Dublin 24, Ireland

Received 23 December 2004; received in revised form 23 May 2005; accepted 29 June 2005

KEYWORDS A testicular varicocele represents an abnormal degree of venous dilatation of the

Testicle; Testes; pampiniform plexus. It is a relatively common condition and may present at scrotal
Varicocele; Doppler pain and swelling. An association with male subfertility is an area of debate. This
ultrasound; Magnetic article describes the present day radiological criteria and imaging techniques to
resonance imaging; aid accurate diagnosis of varicoceles. In addition, the role of the interventional
Therapeutic radiologist in treating this condition is discussed.
embolisation Q 2005 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Introduction (Fig. 1), this is also true in older patients who

A varicocele is an abnormal degree of venous
dilatation in the pampiniform plexus.1 It affects
approximately 15% of men. It can present with
scrotal pain and swelling, or during the investi-
gation of male sub-fertility. Nowadays most are
detected incidentally in patients undergoing scrotal
ultrasound for other reasons and remain clinically
silent. 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. Less frequent
causes of varicoceles include compression of the
renal vein sometimes by tumour, an aberrant renal
vein or an obstructed renal vein. Because varico-
celes are much less common on the right side, the
finding of a right-sided varicocele necessitates
evaluation of the abdomen to exclude an associated
abdominal mass causing compressive symptoms
* Guarantor and correspondent: W.C. Torreggiani, Department
of Radiology, Adelaide and Meath Hospital, Tallaght, Dublin 24,
Ireland. Tel.: C353 141 437 00; fax: C353 141 438 05.
E-mail address: william.torreggiani@amnch.ie
(W.C. Torreggiani).
present with a recent onset varicocele.
The association of varicoceles with sub-fertility
is controversial. In some patients sperm motility
improves after varicocele ablation, but in others it
remains the same.
In this article we will describe the criteria for
diagnosis, particularly emphasizing the present
ultrasound guidelines. Methods and manoeuvres to
aid visualization are discussed, as well as variations
in appearance. In addition the role of the interven-
tional radiologist in treating this disorder is
described.
Diagnosis
Clinical
Varicoceles may be symptomatic with pain and
swelling. The clinical suspicion of a varicocele
depends on the expertise of the evaluating phys-
ician. A senior urologist, for example, is far more
likely to make the correct diagnosis. 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.1 A large varicocele is often described as
a bag of worms surrounding the testis. Dubin and

0009-9260/$ - see front matter Q 2005 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.crad.2005.06.010
Testicular varicoceles
Figure 1 (a) Grey scale ultrasound demonstrates large
varicocele surrounding the right testes. (b) Coronal
gadolinium-enhanced coronal fast low angle shot
(FLASH) MRI image demonstrates large right renal mass
with ipsilateral varices.
Amelar2 devised a useful 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. Although clinical evaluation with Val-
salva manoeuvre is a simple and non-invasive test,
clinical examination is not without limitation. A
study by Orda et al. of 38 males suggests that
clinical assessment is highly subjective.3 In a World
Health Organisation multicentre study on 141 men
with sub-fertility the sensitivity of clinical examin-
ation was approximately 50% for the detection of a
varicocele when compared with venography and it
had a false-positive rate of 23%.4 This high false-
1249
positive rate for clinical examination makes it
imperative that a practising radiologist be familiar
with the radiological features and variations of
testicular varicoceles.
Imaging
In the past, thermography was a widely used
technique but has largely been superseded by
ultrasound5 and will not be discussed further
(Table 1).
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.6,7 In a study by Rifkin
et al. in 21 patients with clinically palpable
varicoceles, good correlation was found when
3 mm was used as the minimum size for diagnosis
of a varicocele.6 Other studies have suggested
2 mm is sufficient to diagnose a varicocele. 5
However, the exact size of the vessel is variable.
A Valsalva manoeuvre is an important component of
the examination and should be performed routinely
as it causes an increase in vessel size and
conspicuousness (Fig. 2). In 1986, MacClure and
Hricak assessed 50 subfertile and 25 control
patients. In the subfertile group 50% had clinically
detectable varicoceles while 68% had ultrasound
evidence of a spermatic vein exceeding 3 mm in
size. In the control group 16% had clinically
detectable varicoceles while 32% had a spermatic
vein exceeding 3 mm on ultrasound.8 This again
suggested the additive importance of ultrasound
over clinical evaluation alone. Unfortunately this
study did not incorporate a group who underwent
venography, which is considered to be the gold
standard. Hamm et al.5 compared scrotal ultra-
sound with venography in 118 patients. In this study
ultrasound was shown to have a sensitivity of 98%
and specificity of 100% compared with venography,
but 2 mm was used as the lower limit for venous
dilatation.4 While the majority of varicoceles are
extra-testicular in location, they may rarely
traverse the testicle itself (Fig. 3).
During the examination, conditions should allow
for maximum visualization while maintaining
patient comfort. The room should be darkened
and a chaperone should be made available if
possible. The procedure should be fully explained
to the patient and also how to perform the Valsalva
manoeuvre. In our institution, it is routine for the
patient to hold the penis in the anatomical position
1250 P. Beddy et al.

Table 1 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 O
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)
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 (technetium-99m- Static images show intra-scrotal accumulation of the labelled red cells. Supine and erect
labelled red blood cells) imaging is obtained. Reflux may be shown on dynamic images

with one hand. This allows easier evaluation of the

exposed testes, as well as allowing the second hand
to be free to pinch the nostrils in order to perform
the Valsalva manoeuvre. We typically perform the
evaluation initially in a supine position followed by
a similar examination with the patient standing. It is
often useful to wait a few minutes before evaluat-
ing the patient in the standing position to allow the
varicoceles to fill. Some varicoceles only become
apparent in this position. We routinely use colour
Doppler as part of the examination (Fig. 2). It 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. Petros et al.9 evaluated 17
sub-fertile men with colour Doppler ultrasound
versus clinical examination. Venography was per-
formed as the gold standard. Venography revealed
14 varicoceles, 93% of which were detected by

Figure 2 (a) There is a varicocele on the left side of the

pampiniform plexus. (b) After Valsalva manoeuvre there
is marked engorgement and prominence of the varico- Figure 3 Sagittal ultrasound of the left testes shows a
cele. Initially the patient is in the supine position and serpentigenous hypoechoic structures transcending the
then erect. Valsalva is attempted in both. testes.
Testicular varicoceles 1251

Figure 4 Spot film demonstrating selective catheter

and guide-wire in the left renal vein and testicular vein.

colour Doppler ultrasound, but only 71% by clinical

examination alone.9 We do not routinely use duplex
ultrasound as the technique is time-consuming and
there is much confusion about its significance.
Scrotal scintigraphy was met with enthusiasm in
the early 1980s, however, the sensitivity was low
and the technique was time-consuming. More
recent studies using dynamic varicocele scintigra-
phy have been more promising especially in the
group with a small or subclinical varicocele.10
Although venography is still considered to be the
gold standard, it is time consuming and invasive. A
normal venogram is one in which is a single
testicular vein is seen up to the inguinal ligament
and into the spermatic cord, there may be a few
divisions as part of the pampiniform plexus. 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. Mars-
mann et al.11 classified the degree of reflux on
Figure 5 Selective venography of left testicular vein
demonstrates dilatation of pampiniform plexus around
the left testes in keeping with a varicocele.
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, respect-
ively.11 In our institution, venography is performed
either in the assessment of difficult or uncertain
cases or more commonly before definitive treat-
ment by venous embolization. It is important to
shield the gonads during venography and treatment
procedures. Pulsed fluoroscopy and image
1252 P. Beddy et al.

Figure 6 Coronal T1-weighted MRI image post-gadoli-

nium shows left-sided varicocele.

capturing should be used during all venographic and

therapeutic procedures.
We typically perform the procedure under local
anaesthetic. Conscious sedation is sometimes used
in very anxious patients but is not essential. We
typically puncture the right common femoral vein
under ultrasound guidance, the jugular vein offers
an alternative approach site. Using a co-axial
system, a 5 F sheath is placed into the common
femoral vein. We use a 5 F standard Cobra catheter
and a hydrophilic guide-wire. The catheter and
guide-wire are then advanced into the inferior vena Figure 7 Spot view of the testicular vein showing coil
cava (IVC) and the renal vein on the left or embolization extending through the length of the
testicular vein.
occasionally directly into the testicular vein on
the right as it enters the IVC. Access to the right
renal vein may be difficult in some cases. The use of resonance imaging (MRI) or computed tomography
a guide catheter helps cannulation of this vessel by (CT), is only occasionally required, for example, to
stabilizing the catheter and guide-wire. After a evaluate the presence of obstructing masses
failed trial with a Cobra catheter we try a more particularly on the right side. When conventional
angled catheter such as a 5 F Omni Selective venography is contraindicated (history of anaphy-
catheter. If we still fail then we directly proceed laxis, etc), magnetic resonance venography (MRV)
to attempt access via the internal jugular vein. is a suitable alternative (Fig. 6). Magnetic reson-
Occasionally we use the basilic vein as an access ance angiography has been used for the assessment
point. The catheter is advanced into the testicular of recurrent varicoceles.12,13
vein over the guide-wire (Fig. 4). Contrast medium
is then injected by hand and images obtained
(Fig. 5). Limited images should be obtained over Treatment
the testes due to their sensitivity to ionizing
radiation. The decision to treat should be based primarily on
Imaging with other techniques, such as magnetic whether it is symptomatic or associated with
Testicular varicoceles
subfertility, and the choice is between surgical
treatment and radiological treatment. Where there
is a trained radiologist, percutaneous embolization
should be the first-line therapy,14 with surgery
reserved for the small proportion of patients who
have failed catheterization. However, the decision
is often based on local bias and availability of local
expertise.
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. Laparoscopic
varicocele ligation has not been shown to be
superior to open surgery and may be associated
with serious complications.15 Barbalias et al.16
compared the three surgical approaches with
percutaneous embolization in a randomised, pro-
spective study. There were similar recurrence rates
with all four techniques. In addition, there was
significant improvement in sperm motility in all
groups, with open inguinal ligation having margin-
ally the best results.16 Post-procedure the return to
normal activities is, however, significantly faster
after embolization compared with surgery. These
results have been seen in other studies.17,18
Percutaneous embolization involves selective
catheterization of the spermatic vein and sub-
sequent occlusion with a sclerosing agent or a solid
embolization coil.19 The procedure is usually
carried out on a day-case basis. Embolization or
sclerotherapy is preceded in all cases by venogra-
phy to both access the size and distribution of the
varicocele, as well as to confirm correct position of
the catheter before embolization. We use coils,
Table 2 Procedural difficulties and their management.
Difficulties
Difficulty puncturing femoral vein
Difficulty accessing proximal testicular vein
Difficulty accessing distal testicular vein for distal embolisation
Vessel spasm
1253
starting distally at the level of the inguinal ligament
and progressing proximally to within 2–3 mm of
renal vein (Fig. 7). Care is taken when placing coils
proximally to ensure that they do not dislodge into
the renal vein. We use 8 mm coils for a standard
varicocele and 10 mm coils for a larger varicocele.
It is important that all collateral and parallel veins
that are visualized are individually cannulated and
occluded. Sclerosing agents such as sodium tetra-
decyl sulphate may also be used. It is imperative
that reflux into the pampiniform plexus is pre-
vented by external pressure at the inguinal crease
before injecting the sclerosant.
The immediate technical success rate is upwards
of 90%.20 Failure of the procedure is usually due to
unsuccessful catheterization or anatomical
variants.21 We have summarized common difficul-
ties and suggested solutions in Table 2. Patients are
discharged within 2 h of the procedure, most
require simple analgesia post-procedure. Anti-
biotics are not given as standard. We advise
patients to avoid sexual activity until they have
resumed their usual functional levels. Long-term
follow-up data have principally been accrued in
studies carried out in sub-fertile men. The marker
of successful therapy in this group is the improve-
ment in semen quality and pregnancy rates post-
varicocele ablation. Kuroiwa et al.22 treated 28 sub-
fertile men with clinically detected varicoceles
with percutaneous embolization, 82% had an
improvement in the grade of varicocele and a
significant improvement in sperm count.22 A recent
large series by Trombetta et al.23 in 560 sub-fertile
men showed improvement in sperm count in 87% at
Management options
(a) Use of micro puncture set for initial femoral puncture
(b) Direct ultrasound guidance puncture of vein
(recommended)
(c) Get patient to perform Valsalva manoeuvre to enlarge size
of femoral vein
(a) A guide catheter or long sheath may aid in stabilising Cobra
catheter
(b) Use of a tracker (micro) catheter to enter testicular vein
(c) Repeat procedure through alternative route such as
jugular vein or basilic approach
(a) Use of hydrophilic catheter and guide wire
(b) Use of micro coils through a tracker catheter
(c) Use of 4 French Cobra catheter instead of 5 French
catheter
(a) Treatment of vasospasm with vasodilators rarely helpful in
venous system
(b) Reattempt after interval (15 minutes) may allow spasm to
abate
(c) Spasm often induced by excessive manipulation. Smooth
technique and experience may reduce frequency
1254
3 months post-procedure. Improved pregnancy
rates are seen in a number of studies, however, a
Cochrane review of five randomized studies of
varicocele repair revealed no overall improvement
in pregnancy rates.23–27 Whether improvements in
sperm quality directly result in increased pregnancy
rates is unclear but many clinicians favour repair of
varicoceles in infertile couples.28 In terms of
symptomatic varicoceles, Alqahtani et al.29
reported 41 patients who underwent percutaneous
embolization for symptomatic disease. They found
that 89.1% of patients reported a significant
improvement at mean follow-up of 22 months.29
Complications are uncommon. Coil migration is rare
and is usually related to release too near to the
renal vein.30 Tungsten coils should be avoided as
there is some resorption of the coil and the long-
term side effects of raised serum tungsten levels
are unknown.31 If a sclerosing agent is used,
thrombosis of the pampiniform plexus is possible,
it occurs in less than 5% of patients, but is
troublesome and requires treatment with anti-
inflammatory agents and antibiotics.32 The indi-
cations for varicocele treatment differ in children
as it may prevent future testicular atrophy and sub-
fertility.33
Conclusion
Testicular varicoceles are an important disorder
leading to significant symptoms in some patients
and associated with sub-fertility in others. Accurate
diagnosis is important as correct treatment may
lead to resolution of symptoms and improvement in
sperm count in sub-fertile patients. As clinical
diagnosis is inaccurate, imaging is usually required
to confirm the diagnosis. Although ultrasound,
including colour Doppler techniques, is the com-
monest method used in diagnosing varicoceles,
venography remains the gold standard. Treatment
may be surgical or radiological, with radiological
treatment resulting in a quicker recovery.
References
1. Demas BE, Hricak H, McClure RD. Varicoceles. Radiologic
diagnosis and treatment. Radiol Clin North Am 1991;29:
619—27.
2. Dubin L, Amelar RD. Varicocele size and results of
varicocelectomy in selected subfertile men with varicocele.
Fertil Steril 1970;21:606—9.
3. Orda R, Sayfan J, Manor H, Witz E, Sofer Y. Diagnosis of
varicocele and postoperative evaluation using inguinal
ultrasonography. Ann Surg 1987;206:99—101.
P. Beddy et al.
4. Comparison among different methods for the diagnosis of
varicocele. World Health Organization. Fertil Steril 1985;
43:575–82.
5. Hamm B, Fobbe F, Sorensen R, Felsenberg D. Varicoceles:
Combined sonography and thermography in diagnosis and
post therapeutic evaluation. Radiology 1986;160:419—24.
6. Rifkin MD, Foy PM, Kurtz AB, Pasto ME, Goldberg BB. The role
of diagnostic ultrasonography in varicocele evaluation.
J Ultrasound Med 1983;2:271—5.
7. Wolverson M, Houttuin E, Heiberg E, Sundaram M, Gregory J.
High-resolution real-time sonography of scrotal varicocele.
AJR Am J Roentgenol 1983;141:775—9.
8. MacClure RD, Hricak H. Scrotal ultrasound in the infertile
man: Detection of subclinical unilateral and bilateral
varicoceles. J Urol 1986;135:711—5.
9. Petros JA, Andriole GL, Middleton WD, Picus DA. Correlation
of testicular color Doppler ultrasonography, physical exam-
ination and venography in the detection of left varicoceles in
men with infertility. J Urol 1991;145:785—8.
10. Prenen J, Van Dis P, Feijen H. Varicocele scintigraphy: A
simplified method for the detection of spermatic vein reflux.
Clin Nucl Med 1996;21:921—7.
11. Marsmann JWP. Clinical versus subclinical varicoceles:
Venographic findings and improvement of fertility after
embolisation. Radiology 1985;155:635—42.
12. Von Heijne A. Recurrent varicocele. Demonstration by 3D
phase-contrast MR angiography. Acta Radiol 1997;38:
1020—2.
13. Varma MK, Ho VB, Haggerty M, Bates DG, Moore DC. MR
venography as a diagnostic tool in the assessment of
recurrent varicocele in an adolescent. Pediatr Radiol 1998;
28:636—7.
14. Hargreave TB. Varicocele—a clinical enigma. Br J Urol 1993;
72:401—8.
15. Soulie M, Seguin P, Richeux L, et al. Urological complications
of laparoscopic surgery: Experience with 350 procedures at a
single center. J Urol 2001;165:1960—3.
16. Barbalias GA, Liatsikos EN, Nikiforidis G, Siablis D. Treat-
ment of varicocele for male infertility: A comparative study
evaluating currently used approaches. Eur Urol 1998;34:
393—8.
17. Sautter T, Sulser T, Suter S, Gretener H, Hauri D. Treatment
of varicocele: A prospective randomized comparison of
laparoscopy versus antegrade sclerotherapy. Eur Urol 2002;
41:398—400.
18. Fretz PC, Sandlow JI. Varicocele: Current concepts in
pathophysiology, diagnosis and treatment. Urol Clin North
Am 2002;29:921—37.
19. Iaccarino V. A nonsurgical treatment of varicocele: Trans-
catheter sclerotherapy of gonadal veins. Ann Radiol (Paris)
1980;23:369—70.
20. Nabi G, Asterlings S, Greene DR, Marsh RL. Percutaneous
embolization of varicoceles: Outcomes and correlation of
semen improvement with pregnancy. Urology 2004;63:
359—63.
21. Keoghane SR, Jones L, Wright MP, Kabala J. Percutaneous
retrograde varicocele embolisation using tungsten embolisa-
tion coils: A five year audit. Int Urol Nephrol 2001;33:
517—20.
22. Kuroiwa T, Hasuo K, Yasumori K, et al. Trans-catheter
embolization of testicular vein for varicocele testis. Acta
Radiol 1991;32:311—4.
23. Schlesinger MH, Wilets IF, Nagler HM. Treatment outcome
after varicocelectomy. A critical analysis. Urol Clin North
Am 1994;21:517—29.
Testicular varicoceles
24. Trombetta C, Liguori G, Bucci S, Ciciliato S, Belgrano E.
Percutaneous treatment of varicocele. Urol Int 2003;70:
113—8.
25. Zuckerman AM, Mitchell SE, Venbrux AC, et al. Percutaneous
varicocele occlusion: Long-term follow-up. J Vasc Interv
Radiol 1994;5:315—9.
26. Evers JL, Collins JA, Vandekerckhove P. Surgery or
embolization for varicocele in subfertile men. Cochrane
Database Syst Rev 2001;1:CD000479.
27. Evers JL, Collins JA. Assessment of efficacy of varicocele
repair for male subfertility: A systematic review. Lancet
2003;361:1849—52.
28. Sandlow J. Pathogenesis and treatment of varicoceles. BMJ
2004;328:967—8.
1255
29. Alqahtani A, Yazbeck S, Dubois J, Garel L. Percutaneous
embolization of varicocele in children: A Canadian experi-
ence. J Pediatr Surg 2002;37:783—5.
30. Cornud F, Belin X, Amar E, Delafontaine D, Helenon O,
Moreau JF. Varicocele: Strategies in diagnosis and treat-
ment. Eur Radiol 1999;9:536—45.
31. Barrett J, Wells I, Riordan R, Roobottom C. Endovascular
embolization of varicoceles: Resorption of tungsten coils in
the spermatic vein. Cardiovasc Intervent Radiol 2000;23:
457—9.
32. Thomas Jr AJ, Geisinger MA. Current management of
varicoceles. Urol Clin North Am 1990;17:893—907.
33. Kass EJ, Belman AB. Reversal of testicular growth failure by
varicocele ligation. J Urol 1987;137:475—6.