varicocele part2

Media file 6:

   Line diagram of a typical bidirectional Doppler
 recording of a stop-type varicocele
 (red) in which flow is stopped by
 a competent valve in the pampiniform
plexus above the level of communicating veins.
The shunt-type of varicocele is depicted in blue.
 Because the valves in the pampiniform plexus
 contiguous to the testicular veins are incompetent
 or absent, venous flow is shunted via communicating
veins into orthograde draining veins; these are shown
 to represent deferential and cremasteric veins at
 contrast venography. On bidirectional Doppler sonograms,
 steady flow is recorded in both retrograde and orthograde fashions.
 Note:
Several factors affect the flow, including
A-The position of the patient,
b- Valsalva maneuvers,

seem diagram in pdf with ;

Recurrence of varicoceles can be as
 high 20% in patients after embolotherapy
and/or surgical ligation of varicoceles
Reference Sakamoto H, Ogawa Y, Yoshida H. 
Relationship between testicular volume and varicocele
 in patients with infertility. Urology. Jan 2008;71(1):104-9. [Medline .

. Intratesticular varicoceles are frequently
 bilateral; however, when they are solitary,
 the intratesticular varicoceles are more
 common on the right side.6
Reference Das KM, Prasad K, Szmigielski W, Noorani N.
 Intratesticular varicocele: evaluation using
conventional and Doppler sonography. AJR Am J Roentgenol.
 Oct 1999;173(4):1079-83. [Medline]. [Full Text

Findings
Ultrasonographic findings in varicoceles include the following:
Tortuous anechoic tubular structures are demonstrated adjacent to the testis.
With the patient in an upright position, the diameter of the dominant vein
 at the inguinal canal measures more than 2.5 mm and is associated with an
 increase in diameter of at least 1 mm during a Valsalva maneuver.

see image in  pdf

Varicoceles can be small to very large, with some enlarged vessels as large as 8 mm in diameter.
Varicoceles can be found anywhere in the scrotum (ie, medial, lateral, anterior, posterior,
 or inferior to the testis).

Color Doppler ultrasonographic

  imaging can be helpful in differentiating venous channels from
epidermoid cysts or spermatoceles when doubt exists.
Bidirectional Doppler ultrasonography performed with
 the patient in the upright position with quiet
 respiration shows a shunt type of flow in 86% of
patients in whom insufficient distal valves allow
spontaneous and continuous reflux from the ISV into
the cremasteric vein and the vein of the vas deferens.

see image in  PDF

Bidirectional Doppler ultrasonography performed with
the patient in the upright position with quiet respiration
 shows a stop type of flow in 14% patients in whom intact
 valves allow only sporadic reflux from the spermatic vein
 into the pampiniform plexus with a Valsalva maneuver.

Doppler ultrasonography can be used to grade venous reflux

  as static (grade I), intermittent (grade II), or continuous (grade III)
Effective sclerotherapy is indicated when venous dilatation resolves
and the overall diameter of the veins decreases.
Intratesticular varicoceles may appear as a vague hypoechoic area
in the testis. They appear tubular or oval shaped and usually
lie near the mediastinum testis.

see image in pdf

 Sigmund G, Gall H, B?hren W. Stop-type and shunt-type varicoceles:
venographic findings. Radiology. Apr 1987;163(1):105-10. [Medline]. [Full Text].
Hamm B, Fobbe F, S?rensen R, Felsenberg D. Varicoceles: combined sonography
 and thermography in diagnosis and posttherapeutic evaluation. Radiology.
 Aug 1986;160(2):419-24. [Medline]. [Full Text].
Dubin L, Amelar RD. Varicocele size and results of varicocelectomy
in selected subfertile men with varicocele. Fertil Steril. Aug 1970;21(8):606-9. [Medline].
Lund L, Hahn-Pedersen J, Hljhus J, Bojsen-Mlller F. Varicocele testis evaluated by CT-scanning.
 Scand J Urol Nephrol. Apr 1997;31(2):179-82. [Medline].
von Heijne A. Recurrent varicocele. Demonstration by 3D phase-contrast MR angiography.
 Acta Radiol. Nov 1997;38(6):1020-2. [Medline].
Paz A, Melloul M. Comparison of radionuclide scrotal blood-pool
 index versus gonadal venography in the diagnosis of varicocele.
 J Nucl Med. Jun 1998;39(6):1069-74. [Medline]. [Full Text].
Gandini R, Konda D, Reale CA, et al. Male varicocele: transcatheter
foam sclerotherapy with sodium tetradecyl sulfate--outcome in 244 patients.
 Radiology. Feb 2008;246(2):612-8. [Medline].
Barrett J, Wells I, Riordan R, Roobottom C. Endovascular embolization of varicoceles:
 resorption of tungsten coils in the spermatic vein. Cardiovasc Intervent Radiol.
 Nov-Dec 2000;23(6):457-9. [Medline].
Varma MK, Ho VB, Haggerty M, Bates DG, Moore DC. MR venography as a diagnostic tool
 in the assessment of recurrent varicocele in an adolescent. Pediatr Radiol. Aug 1998;28(8):636-7. [Medline].
Zini A, Boman J, Baazeem A, Jarvi K, Libman J.
 Natural history of varicocele management in the era of
intracytoplasmic sperm injection. Fertil Steril. Jan 25 2008;epub ahead of print. [Medline].

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