Since they seldom cause any pain or discomfort, most varicoceles are discovered during routine physical exams or exams associated with an infertility workup. Physicians typically diagnose a varicocele by asking the man to stand up, take a deep breath, and bear down while the physician feels the scrotum above the testicle. If a man has a low sperm count or a low testosterone count, the man should be examined for the possibility of a varicocele.
Sometimes, a boy or a man may be concerned because he feels a mass in his scrotum, or because the genitals look asymmetrical or abnormal. On occasion, the genitals are extremely abnormal and may hang way down, a condition that is called a “sagging scrotum.” One patient who experienced an extreme sagging scrotum wrote about his experience in Esquire Magazine.
Varicocele Physical Evaluation
Varicoceles have been arbitrarily divided into three grades based on physical examination findings. A grade 1 varicocele is only palpable during or after the patient performs a movement called the Valsalva maneuver. A grade 2 varicocele is palpable by the doctor without the need for the Valsalva maneuver, and a grade 3 varicocele can be seen.
If a varicocele is suspected, a physician may order a scrotal ultrasound test. Subclinical varicoceles are lesions not detected by routine examination. These lesions are smaller than “clinical” varicoceles, but they can affect fertility.
The duplex ultrasound is currently considered the best non-invasive way to identify and confirm the presence of varicoceles. First, a thorough ultrasound of the testis is performed. The diameter of the veins can be measured and abnormalities may be identified. Almost one-third of men with infertility have an abnormal finding on the ultrasound that was not suspected during the physical examination.
Ultrasound Doppler Evaluation
The second part of the ultrasound evaluation measures the blood that flows past the probe when the patient pushes down. This blood flow confirms the varicocele. This blood flow can be seen and heard.
A Doppler stethoscope will amplify the sound of blood moving past a varicocele. At rest, only the pumping of the artery should be heard. The blood flow in the veins is so slow that no sound can be heard. When the patient pushes down, more blood flows backwards into the scrotum and can be heard as a rushing sound.