Varicocele Grading in Radiology: Ultrasound-Based Classification

Introduction
Varicocele is an abnormal dilatation and tortuosity of the pampiniform venous plexus within the spermatic cord, caused by incompetent or absent valves in the internal spermatic vein.
It is the most common surgically correctable cause of male infertility and is more frequent on the left side due to anatomical drainage into the left renal vein.
Radiology, especially Doppler ultrasound, plays a crucial role in diagnosis and grading.

---

Imaging Modalities

• Ultrasound (USG) – First-line modality; measures vein diameter and assesses reflux.
• Color Doppler – Detects venous flow direction and Valsalva-induced reflux.
• MRI / CT – Rarely required; used in atypical or secondary varicoceles.
• Venography – Gold standard for interventional planning, rarely done for diagnosis alone.

---

Ultrasound Diagnostic Criteria

• Dilated pampiniform plexus veins >2–3 mm in diameter (measured in supine position).
• Augmentation in diameter and reflux during Valsalva maneuver.
• Color Doppler – Retrograde venous flow lasting >1 second with Valsalva.

---

Sarteschi Grading System for Varicocele (Ultrasound/Doppler)

Grade	Ultrasound Criteria	Key Notes
Grade 1	Small, tortuous intratesticular or peritesticular veins visible only after Valsalva maneuver; reflux confined to peritesticular veins	No spontaneous reflux at rest
Grade 2	Small peritesticular veins with reflux only during Valsalva, no visible pampiniform plexus dilatation at rest	Subtle on B-mode, requires Doppler
Grade 3	Dilated pampiniform plexus veins ≥3 mm at rest, reflux induced only by Valsalva maneuver	No spontaneous reflux
Grade 4	Dilated pampiniform plexus veins ≥3 mm with spontaneous reflux at rest, further increase during Valsalva	Clear on grayscale and Doppler
Grade 5	Markedly dilated, tortuous pampiniform plexus veins >3.5–4 mm with continuous spontaneous reflux and associated testicular changes (atrophy/hypotrophy)	Severe, often clinically obvious

Measurement & Technique Notes:

• Measure in longitudinal plane at the upper pole of the testis.
• Standing position increases sensitivity for reflux detection.
• Reflux duration >1 second is considered significant.
• Use color + spectral Doppler to confirm venous flow reversal.

Advantages of Ultrasound Grading

• Objective measurement of venous diameter.
• Detection of subclinical varicoceles.
• Useful for pre- and post-treatment evaluation.

---

Limitations

• Operator dependent.
• Valsalva effort may vary between patients.
• Cannot always differentiate primary from secondary varicocele (needs further evaluation for secondary causes).

---

Secondary Varicocele Clues

• Right-sided isolated varicocele.
• Sudden onset in older male.
• No change in diameter with Valsalva.
• Associated retroperitoneal mass on imaging.

---

Treatment Relevance

• Surgical ligation or embolization considered in symptomatic, large, or infertility-associated cases.
• Ultrasound grading guides clinical decision-making and follow-up.

---

Key Takeaways

• Ultrasound with Doppler is the gold standard for grading varicoceles.
• Diameter >3 mm with reflux >1 second on Valsalva is diagnostic.
• Grading aids in standardizing communication between radiologists and urologists.

---

References

1. Gat Y, et al. Human Reproduction Update. 2001;7(5):486–495.
2. Chiou RK, et al. AJR Am J Roentgenol. 1997;169(3):687–690.
3. Liguori G, et al. J Urol. 2004;171(6 Pt 1):2634–2637.