Varicocele presents due to male-factor subfertility, orchalgia, or as an incidental finding on routine physical examination. Varicocele is diagnosed primarily by physical examination of the cooperative, relaxed, and warm patient in the upright position. To limit the effect of cremasteric retraction the testes are gently supported. Inspection and palpation of the scrotal contents is directed to a point just superior to the testes. Grade Ill (large) varicoceles are visibly thickened veins above the testis. Grade II (medium) varicoceles are palpable in the standing patient without a Valsalva's maneuver. Grade I (small) are palpable only with a Valsalva's maneuver. Ipsilateral testicular atrophy may also be present based on measurement or comparison to the contralateral testes. Isolated varico-cele on the right may be associated with renal tumors, retroperitoneal masses, or lymph-adenopathy and should be further evaluated for causes of proximal venous compression. Dilated veins can be distinguished from a cord lipoma because the lipoma will tend to slip from grasp when genltly pinched (14).

Additional diagnostic studies include ultrasound, thermography, venography, scintigraphy, and MRI but are not recommended in the routine evaluation of the infertile male unless the physical examination is equivocal. When faced with an inconclusive physical examination and a high index of suspicion, scrotal ultrasonog-raphy may provide evidence of subclinical varicocele based upon venous caliber and demonstration of reversed venous flow during Valsalva's maneuver. Furthermore, ultrasonography is noninvasive and can identify other pathologic processes in the testes, epididymis, and spermatic cord including objective measurement of testicular dimensions with greater accuracy than physical examination or orchidometer (15). A subclinical varicocele is found only on scrotal sonography and not on physical examination. According to Jarrow et al., only palpable varicoceles are clearly linked to male subfertility (16).

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