Varicoceles are defined as dilations of the veins of the testicular pampiniform plexus, which are believed to be caused by absent or incompetent valves in the internal spermatic veins. The diagnosis of a clinically significant varicocele is generally made on physical examination of the scrotum and its contents. The patient is examined in the supine and standing position with the scrotum warmed first with a heating pad. This promotes relaxation of the scrotal dartos muscle and facilitates accurate evaluation for varicocele. The scrotum should be inspected carefully for any easily visible dilated veins. The spermatic cord should be palpated between thumb and forefinger for palpable tortuous veins. Both spermatic cords should be palpated while the patient performs a Valsalva maneuver in the upright position.
Varicoceles are graded I through III using the system outlined in Table 1. Grade I varicoceles are small, Grade II moderate and Grade III, large. Varicoceles should collapse in the supine position. If the varicocele remains prominent with the patient supine, this finding suggests a mechanical obstruction to testicular venous outflow from a retroperitoneal mass (sarcoma, lymphoma or a renal tumor with venous thrombus). An abdominal ultrasound or CT scan should be obtained to evaluate the retroperitoneum in these men.
Scrotal ultrasonography with color flow Doppler imaging with the patient upright and supine may prove useful in equivocal cases or in patients with a body habitus that makes accurate physical examination of the scrotum impossible. Using ultrasonography, the diameter of the internal spermatic vein can be measured and retrograde flow through the vein during Valsalva maneuver documented. Veins that are greater than 3.5 mm can generally be detected on physical exam. Those that are 2.5 mm or larger but are not palpable and have been termed subclinical varicoceles. The need for diagnosing and treating subclinical varicoceles in controversial. Reports have indicated that repair of small palpable or subclinical right varicoceles may be beneficial if present in conjunction with a larger left sided varicocele. A recent meta-analysis by Marmar et al. clearly shows a significant increase in pregnancy rates after microsurgical varicocelectomy.
A multi-center WHO study on the influence of varicocele on fertility parameters demonstrated that the mean testosterone (T) concentration of men older than 30 years of age with varicoceles was significantly lower than that of younger patients with varicoceles, whereas this trend was not seen in men without varicoceles. When exogenous hCG is administered to men with varicoceles, a blunted T response is observed compared to controls without varicoceles. Repairing varicoceles appears to improve serum testosterone (T) levels. This observation was made over twenty years ago by Comhaire and Vermeulen and was confirmed recently in a larger series by Su, et al.Taken together, these findings indicate that varicoceles result in abnormal Leydig cell function in some men, and these patients may also be the ones to most benefit from surgical repair.
The abnormalities of semen parameters in infertile men with varicocele were first objectively described by Macleod in 1965 In that study, Macleod observed that the vast majority of semen samples, obtained from 200 infertile men with varicocele, were found to have an increased number of abnormal forms, decreased motility and lower mean sperm counts. This 'stress pattern', which is also characterized by an increased number of tapered forms and immature cells, was also reported in other studies. However, other investigators have shown that the characteristic stress pattern is not a sensitive marker for varicocele, and believe that it is not diagnostic of this pathology. A large number of studies have evaluated the effects of varicocelectomy on semen parameters. Most of these studies have demonstrated an improvement in sperm density with or without a concomitant increase in sperm motility and morphology after varicocelectomy, suggesting a cause and effect relationship between varicocele and abnormal semen parameters. The impact of the grade of varicocele on the magnitude of improvement in semen quality after varicocelectomy is not surprising. Steckel et al., reported that men with larger varicoceles present with lower sperm densities, and show greater relative improvement in semen quality after microsurgical repair than men with smaller varicoceles.