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How about tests? Are they necessary to confirm the diagnosis?
Tests like scrotal ultrasound (Figure 3) are performed to corroborate the clinical diagnosis, and are also useful in measuring vein size and the degree of reflux (backflow) of blood. Testis size can be measured at the same time, and gives some indication of its function. Besides these, hormonal studies, of serum FSH, LH, and testosterone, may be performed to assess testicular function. More elaborate tests like venography (phlebography) are usually performed for research purposes or if there is recurrence after surgery (Figure 4), to look for anomalous venous pathways. A venogram is also necessary if therapeutic embolization is planned as a treatment option. It must be stressed, however, that the diagnosis of a varicocele is essentially clinical, and examination of the patient should therefore only be performed by an expert in varicoceles. Varicoceles that are too small to be felt by experts are usually not significant (important from the standpoint of infertility), and it is doubtful if treatment for such varicoceles can confer benefit. The entity of 'sub-clinical' varicocele, which means a varicocele that cannot be felt clinically but can be seen ultrasonographically, was popular in the eighties, but results of surgery in these patients were very poor. The concept of a sub-clinical varicocele has now been abandoned. Further, it has been shown that reflux (backflow) of blood into the scrotum occurs even in normal males on coughing (or the performance of a Valsalva manoeuvre) and that this is not indicative of a varicocele. Reflux of venous blood during rest or quiet respiration is considered more significant (see Figure 3). Another reason for performing tests is medico-legal. Since guarantees about the efficacy of varicocele surgery cannot be always given even at the best microsurgical centers, such tests are sometimes important to establish bona fides and ethical intentions.
Figure 3: Shows an uncommon, large, refluxing varicocele on the right side. (Picture courtesy: Andromeda Andrology Center, Hyderabad, India)
 
Figure 4: Shows phlebograms (venograms) of two patients with unusual presentations of varicocele. (Picture courtesy: Andromeda Andrology Center, Hyderabad, India)
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