Varicocele Assessment Tools

  1. Principles in Varicocele Clinical Examination
  2. Varicocele Classification
  3. Scrotal Triplex Principles
  4. Reflux Classification
  5. ISUD Reference System
  6. Indications for Surgical Treatment of Varicocele: the 10 "YES" answers
  7. LIterature References

Principles in Varicocele Clinical Examination

  • The patient is examined in the supine and standing position in a warm room in order to facilitate scrotal muscle relaxation and carry out an accurate evaluation.

  • Venous distention should reduce significantly, when the patient from the standing position resumes to supine position. If not, the finding is evaluated and may indicate a mechanical obstacle in the testicular blood reflux, as happens in vein thrombosis or retroperitoneal mass. The scrotum should be initially thoroughly inspected with the eye to identify any potentially occurring visible dilated veins. 

  • When the patient performs a Valsalva maneuver, both testes should be evaluated at the same time. The spermatic tone should be evident upon palpation between the thumb and rest of fingers. 
  • The Valsalva Test should be carried out in such a way so as to gradually increase intraabdominal pressure.

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Varicocele Classification

The degree of Varicocele is graded based on the following Scale:



Table 1: Varicocele Classification Table


no varicocele



evident only with scrotal Ultrasound with Flow Doppler


not visible, palpable only with a Valsalva maneuver


not visible, palpable without a Valsalva maneuver


visible through the scrotum (inpsection) and palpable

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Scrotal Triplex Principles

Scrotal Ultrasound with Color Flow Doppler is a useful tool in the diagnostic approach of Varicocele.  During screening, the following principles have to be followed: 

  • The patient is examined in the supine position; also in the standing position if the result is not positive.
  • The examination includes measurement of the internal spermatic vein diameter and identifying potential vein blood reflux during a Valsalva maneuver.
  • Veins with diameter less than 3mm are considered to be cases of  "Subclinical Varicocele" and their surgical restoration seems to be of no clinical value. However, studies have demonstrated that should there be Clinical Varicocele on the left and Subclinical Varicocele on the right,  these should be treated bilaterally. 

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Reflux Classification

The degree of Reflux degree is graded according to the following Scale:


Grade Description

Table 2: Assessment Scale for Pelvic Floor Muscles


no reflux


very short in duration (<1 second), considered to be normal


lasts 1-2 seconds and disappears before the completion of Valsalva maneuver


lasts longer than 2 seconds and keeps on throughout the whole Valsalva maneuver

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ISUD Reference System

ISUD has introduced a new Reference System for Varicocele, for practical reasons so as to facilitate understanding among Urologists. 

For every patient, the evaluation report includes 2 numbers for every testis (the first one in Latin number) that indicate the Varicocle degree/ Reflux degree respectively.  To make the system even simpler: 

  • Subclinical Varicocele is characterized as Grade Ια.
  • The left side is always mentioned first, as it is the most frequently affected. 

Thus, should a patient's evaluation report be: Varicocele ΙΙ2/01, this is analyzed as follows:

ΙΙ2= left, Varicocele Grade ΙΙ with Reflux Grade 2

01=righ, NO Varicocele (distention >3mm) with Reflux Grade 1 (normal)

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Indications for Surgical Treatment of Varicocele: the 10 "YES" Answers

Check if the answer to all following questions is YES.

1. The couple have not achieved pregnancy after 1 year of regular attempts to conceive without protection? YES
2. Has Varicocele been confirmed with physical, ultrasound or other examination? YES
3. Do you observe reduced testicular volume on the Varicocele side?  YES
4. Is the initial spermodiagram abnormal? YES
5. Are initial FSH values within normal levels? YES
6. Have lab tests been repeated after 4-12 months? YES
7. Does the spermodiagram keep being abnormal? YES
8. Do FSH values keep being within normal levels? YES
9. Have you evaluated ovulation and tubal patency in the female partner? YES
10. Is age above 38 years old? YES

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