Varicocele is the enlargement of the veins (veins) of the testicles. It is an important disease because it causes clinically infertility and erectile dysfunction. It is possible to treat with surgery (surgery) with a high rate of success. Varicocele classification (grade) is made by clinical and scrotal color Doppler ultrasonography.

In the classification (grade) system we use in the examination, we make the patient’s standing and intra-abdominal pressure increase according to the expansion of the veins. In this article, I will give information about the classification of varicocele, taking into account my own experiences.

How is varicocele examination done?

Varicocele examination must be done standing up. Varicocele is detected when the patient is standing, closing his mouth and nose and inflating his abdomen by breathing deeply. Because the enlarged veins will drain in the supine position, it becomes difficult to understand that there is a varicocele. Especially low-grade varicocele cases are overlooked during inpatient examination. In patients with grade-3 varicocele, long-term enlarged vein packs may be palpable even during inpatient examination.

Despite this, the right thing to do is to perform an outpatient examination. Another advantage of the outpatient examination is that it does not miss the inguinal hernia. Since the hernia sac will disappear when the patient is in the supine position, the hernia examination must be done while the patient is standing and straining.

Why is varicocele grade done, why is it important?

In general, classification is made for many diseases. This is called ‘staging’, ‘grade’, ‘grading’, ‘scoring’ and ‘grading’. Varicocele grading is done for the following reasons and is important:

• A universal standardization of the disease is aimed
• Allows an objective assessment of the disease
• Provides objectivity and standardization in diagnosis, treatment and follow-up

Which parameters are taken into account when making varicocele grade?

Some parameters are taken as a basis while staging, that is, grading, of varicocele disease. Accordingly, the staging of the disease is made.

In the outpatient examination performed by the urologist, only the enlargement of the testicular veins is taken into account. Testicular size and condition of structures within the scrotum are not taken into account. This assessment is a relative assessment. It is a scoring system that has been used for a long time.

Ultrasonic evaluation is based on millimetric dilation of testicular veins. At rest and with deep breathing and holding, the diameters of the veins change. In the case of deep breathing (Valsalva maneuver), the vein diameter will increase if there is a varicocele, as the pressure inside the vein increases.

How and with which methods is varicocele grade done?

We attach importance to the grading of the disease in varicocele examination. We usually write the grade of each varicocele in the file of the patients we diagnose. The classification system, especially clinical, that is, made by examination, is not very complicated. For this reason, there are no serious differences according to the examiner. Another classification system is the classification using scrotal ultrasound (scrotal USG). A little more experience is required here. Patient compliance is important for a healthy evaluation.

Varicocele staging (grade) is done in two main ways:

• Grading system made clinically, namely by examination
• Grading with scrotal color Doppler ultrasonography

How is varicocele graded by examination?

The urology doctor performs an outpatient examination of varicocele patients and evaluates the varicocele grade, that is, the scoring. Here, manual and visual examination of testicular veins is based. For the first time with the examination, in 1970, Dr. Dubin and Dr. We use the system defined by Amelar. This grading system does not include testicular volume and information. The system is based only on palpation and observation. It is a widely used method. The varicocele grade on examination is as follows:

Grade 1: Varicocele is detected when the patient is standing and in the straining position (Valsalva maneuver).

Grade 2: Enlarged testicular veins (varicocele) are detected in the examination performed without straining while the patient is standing.

Grade 3: When the patient is examined standing up, a clear varicocele is seen in the upper part of the scrotum when viewed with the naked eye without straining and inflating the abdomen. Testicular veins are markedly enlarged.

How to grade varicocele with ultrasonography?

There is no universally used standard varicocele classification system accepted as ultrasonographic. There are some systems used for this purpose. I will try to summarize them here.

First, the testicular veins and the diameter of the entire venous plexus are measured while the patient is in the normal supine position. Then it is evaluated with color Doppler USG and reflux is checked during Valsalva. Re-evaluation is done while standing.

There are 2 methods that are frequently used in the evaluation of varicocele with scrotal color Doppler USG:

• Grading system made by Lorenc
• Classification by Sarteschi

Lorence classification (grade system): According to this system, varicocele is divided into 4 degrees according to vein diameters in standing and lying positions.

Grade 1: There is no dilatation of the veins. There is enlargement of the spermatic veins (testicular veins) in the inguinal region with the patient’s straining (Valsalva maneuver).

Grade II: There is enlargement of the spermatic veins at the upper end of the testis

With the Valsalva maneuver, there is reflux (backflow) in the veins in the upper part of the testis.

Grade III: There is no significant enlargement of the veins when the patient is lying supine. There is reflux in the examination performed while the patient is standing towards the lower part of the testis. There is reflux on examination with Valsalva in the region that fits the lower end of the testis.

Grade IV: There is reflux in the supine position.

Has reflux during Valsalva

Grade IV: There is dilatation of the spermatic veins. Even without Valsalva there is reflux.

Starteschi classification (grade): Here, varicocele is divided into 5 stages according to the presence of reflux status and testicular atrophy.

Grade I: Only during Valsalva there is reflux at the level of the inguinal region, the scrotum is normal, there is no testicular atrophy

Grade II: During Valsalva, there is reflux in the upper region of the pampiniform plexus. There is no deformity and testicular shrinkage in the scrotum.

Grade III: There is reflux in the lower level veins in the lower parts of the scrotum during Valsalva. The scrotum and testis are normal.

Grade IV: There is spontaneous reflux during Valsalva. Scrotal deformity and testicular atrophy are suspected.

Grade V: There is spontaneous reflux without straining in the enlarged testicular veins at rest. Reflux increases with Valsalva. It is always present with testicular atrophy.

What should be the diameter of the vein in order to diagnose varicocele in scrotal USG?

In order to diagnose varicocele on ultrasound, the measured vein diameter is important. If a vein diameter of 2.5-3 mm or more is measured, then it is possible to talk about clinically significant varicocele. (Tsili AC, Xiropotamou ON, Sylakos A, Maliakas V, Sofikitis N, Argyropoulou MI. Potential role of imaging in assessing harmful effects on spermatogenesis in adult testes with varicocele. World J Radiol 2017; 9(2): 34-45).

Grading according to the vein diameter in the ultrasonic examination performed without straining in the supine position is as follows:

• Grade 0: Spermatic vein diameter is less than 2 mm
• Grade I: Spermatic vein diameter is between 2-3 mm
• Grade II: Spermatic vein diameter is 3 mm or more.

Hadhramout University Journal of Natural & Applied Sciences, Volume 15, Issue 1, 2018.

Is ultrasound absolutely necessary for varicocele?

Scrotal ultrasonography is not necessary to diagnose varicocele. The diagnosis of varicocele is easily made by examination. Ultrasonography gives objective information about the dimensions of the testis, the internal structure of the testis, and other scrotal contents such as the epididymis.

In addition, varicocele cases that cannot be detected manually in physical examination can be detected by scrotal ultrasonography. This type of varicocele, that is, varicoceles that are not palpable on examination and can be detected by USG, are called “subclinical varicoceles”.

Another advantage of scrotal USG is that it does not contain radiation. Therefore, it can be used easily in every patient and in children. There are no complications or risks.

Scrotal ultrasonography in childhood (adolescent) varicocele patients

Varicocele is common in adolescents (before 18 years of age). It is mostly seen on the left side. In this age group, an average of 57.8-14.1 varicoceles is seen. Over time, more than 20% of patients develop testicular atrophy if left untreated. USG is a valuable diagnostic method in the evaluation of testicular volume in these patients. If the volume difference between the two testes with scrotal USG is 2cc (ml) or more, this is not normal and there is testicular damage. Surgery should be performed with microsurgery.

There are no scientific studies on the follow-up of adolescent varicocele cases. These cases require surgery. Different from adults, testicular atrophy due to varicos in pediatric patients recovers approximately 70% with surgery. USG is also important in the postoperative follow-up of childhood varicoceles.

In summary: Varicocele grading is done to provide a standardization in the diagnosis, treatment and follow-up of the disease. It is a classification system based on the dilation of testicular veins (veins). There are two ways to classify. Grade system according to the patient’s outpatient examination and grade system using scrotal color Doppler ultrasound. The enlargement of the veins is evaluated in mm with scrotal USG. In routine clinical practice, the grade system is generally used according to manual examination. The use of USG is not absolutely necessary in patients with varicocele. The use of USG is important as it gives more objective information about testicles and other scrotal contents. We generally recommend our patients to have scrotal USG.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY