The small vessels of the pampiniform plexus normally range from 0.5–1.5 mm in diameter. Dilatation of these vessels greater than 2 mm is called a varicocele.
Varicocele can be reliably diagnosed with ultrasound, which will show dilatation of the vessels of the pampiniform plexus to greater than 2 mm. The patient being studied should undergo a provocative maneuver, such as Valsalva's maneuver (straining, like he is trying to have a bowel movement) or standing up during the exam, both of which are designed to increase intra-abdominal venous pressure and increase the dilatation of the veins. An ultrasound machine that has a Doppler mode can see blood reverse direction in a varicocele with a Valsalva, increasing the sensitivity of the examination.
In accordance with Sarteschi, varicocele can be divided into five grades according to the characteristics of the reflux and its length, and to changes during Valsalva’s manoeuvre. Color Doppler Ultrasound (CDU) classification of varicocele
Grade 1 is characterised by the detection of a prolonged reflux in vessels in the inguinal channel only during Valsalva’s manoeuvre, while scrotal varicosity is not evident in the previous grey-scale study.
Grade 2 is characterized by a small posterior varicosity that reaches the superior pole of the testis and whose diameter increases after Valsalva’s manoeuvre. The CDU evaluation clearly demonstrates the presence of a venous reflux in the supratesticular region only during Valsalva’s manoeuvre.
Grade 3 is characterised by vessels that appear enlarged to the inferior pole of the testis when the patient is evaluated in a standing position, while no ectasia is detected if the examination is performed in a supine position. CDU demonstrates a clear reflux only under Valsalva’s manoeuvre.
Grade 4 is diagnosed if vessels appear enlarged, even if the patient is studied in a supine position; dilatation increases in an upright position and during Valsalva’s manoeuvre. Enhancement of the venous reflux after Valsalva’s manoeuvre is the criteria that allows the distinction between this grade from the previous and the next one. Hypotrophy of the testis is common at this stage.
Grade 5 is characterised by an evident venous ectasia even in an upright position. CDU demonstrates the presence of an important basal venous reflux that does not increase after Valsalva’s manoeuvre.
Scoring System for Color Doppler Ultrasound (CDU) Diagnosis of Varicocele
Maximum vein diameter (mm)
<2.5 0 0
>/= 4.0 3
Plexus/sum of diameter of veins
No plexus identified 0
Plexus (+) with sum diameter <3 mm 1
Plexus [+) with sum diameter 3-5.9 mm 2
Plexus (+) with sum diameter >/=6 mm 3
Change of flow velocity on Valsalva maneuver
<2 cm/s or duration <1 second 0
Total score 0-9
A total score of 4 or more determines the presence of a varicocele by CDU.