Extended imaging for varicocele

[Ying Ying Kho]

Hi Stephen,

Do you extend imaging to
Left kidney when there is left varicocele
Right hypochondria along IVC when there is right varicocele
And both when there are bilateral varicocele?
Noted there are consensus paper on this, but the red flag can be hard to determined (sudden onset, not resolving… )
Thank you!

[Stephen Bird]

It is a classical bit of teaching that says we should look at the kidneys and IVC when we encounter a varicocele.
So yes, I do it,
BUT for 35 years it has NEVER given me an interesting diagnosis,
I bet if I forget one day it will be the case that I miss,
Sometimes the things we do are very low yield and I think this is a good example.
When I see a large left sided varicocele I am more interested in the left testicular vein incompetence and I document this. I also look at the left renal vein / SMA / Aorta relationship and do Doppler of the left renal vein as it passes between the SMA and aorta. I also measure the left renal vein where it is compressed, and then Doppler the left renal vein to the left of the compression point where it is dilated.

The measurements I use are

>10mm AP Diameter for the left renal vein to the left of the compression
PV <15cm/sec for the left renal vein to the left of the compression
At SMA, left renal vein PV>110cm/sec,
At SMA, left renal vein AP Diameter <2mm

There are 2 theories about this so called nutcracker phenomenon.

One is that there is direct anatomical compression of the left renal vein (this is the classic theory)
But now another theory is that the left testicular / (ovarian vein in a female with pelvic venous congestion) has primary valvular incompetence and the blood simply chooses to pass down the vin and less blood passes through the left renal vein and this leads to a pseudo compression appearance.
You can test it by scanning the patient in a head down trandelenberg position and see if the "compression" disappears. This position removes the gravity effect that is pushing blood down the testicular vein.

It is interesting !

Steve.

[Author]

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