Combined Supine and Standing Imaging for Varicocele: An Improved Diagnostic Approach

Summary

Varicocele relies heavily on angiographic diagnostic techniques for disease-related examination and assessment. In order to diagnose varicocele better, we combined supine and standing positions for varicocele imaging, and contrast-enhanced ultrasound is used for patients with inconspicuous reflux. This approach facilitates the early detection, diagnosis, and treatment of varicocele.

Abstract

Varicocele, one of the main diseases affecting male reproductive health, relies heavily on angiographic diagnostic techniques for disease-related examination and assessment. Traditional varicocele angiography often employs a supine position to facilitate the relaxation of the groin area muscles, the insertion of the angiography catheter, and imaging. However, the supine position may cause blood reflux, thus underestimating the clinical incidence of varicocele, particularly resulting in missed diagnoses of right-sided or bilateral varicoceles. To address this issue, this study proposes the combined use of supine and standing positions for varicocele imaging. The standing position increases lower abdominal pressure, making the degree of varicosity more prominent in the images. Compared to the sole use of the supine position, the method employed in this study effectively reduces the misdiagnosis rate of right-sided or bilateral varicoceles. This approach aims to facilitate the early detection, diagnosis, and treatment of varicocele, effectively reducing the potential threat of the disease to male reproductive health. It also helps improve the accuracy of disease assessment, providing more references for selecting subsequent treatment plans.

Introduction

Globally, infertility has gradually emerged as an issue of pressing concern for clinicians and researchers, with related disorders receiving significant attention. Among these, varicocele (VC) is considered one of the primary causes of male infertility, especially with an incidence rate reaching up to 80% in the secondary infertile population¹. Accurate and timely diagnosis for such diseases is pivotal, as it directly dictates the subsequent choice of treatment and its efficacy.

The conventional diagnostic method for varicocele primarily relies on clinical manifestations and physical examinations². Color Doppler ultrasound stands as the preferred method of diagnosis for varicocele, yet its detection rate is contingent on the examiner's experience³. In practice, many sonographers opt to conduct the examination solely in a supine position. However, compared to the standing position, the abdominal pressure is reduced in the supine position, potentially leading to overlooked or underestimated lesions⁴, which consequently influences treatment decisions and outcomes.

To more accurately diagnose varicocele, modern medical research has begun to explore additional diagnostic methods. Contrast-enhanced ultrasound (CEUS), a technique for assessing microvascular perfusion⁵, boasts superior vascular imaging capabilities and has been extensively applied to organs such as the liver⁶, breast⁷, and kidney⁸, but its application in varicoceles remains limited. This study proposes an innovative approach: combining imaging in both the supine and standing positions for varicocele. In a standing posture, due to increased lower abdominal pressure, varicosities appear more pronounced during imaging. In conjunction with contrast techniques, reflux in patients can be observed more directly. This method not only significantly enhances diagnostic accuracy and reduces the risk of missed diagnoses, but it also provides clinicians with a more comprehensive view of the disease, enabling more precise assessment and subsequently a more appropriate treatment plan. In summary, this study, aims to offer clinicians and researchers a novel and more effective diagnostic tool, addressing the growing public health concern of varicocele more effectively.

Protocol

This study received approval from the Shanghai Hospital of Planned Parenthood Research. The diagnostic criteria, surgical indications, and contraindications are in line with the expert consensus of the "Guidelines for Andrological Diagnostics and Treatment," the "Chinese Andrology Society," and the "European Association of Urology Sexual and Reproductive Health Guidelines." Patients with female partners suffering from diseases affecting fertility were excluded from this study. Informed consent was obtained from the patients enrolled in the study.

1. Instruments for operation

1. Ensure the availability of sterilized instruments and other equipment mentioned in the Table of Materials.

2. Pre-examination preparations

1. Ensure the patient is not allergic to the contrast agent.
2. Configure the ultrasound settings using the ultrasound machine, i18LX5 probe, with a frequency of 5 MHz, a mechanical index of 0.07, dynamic range of 50-55 dB, base wave mode adjusted to the area of interest, and harmonic mode adjusted to below the area of interest.

3. Combined varicocele angiography examination

1. Have the examinee first take a supine position (Figure 1).
2. Use the probe perpendicular to the examinee's longitudinal axis to conduct a two-dimensional ultrasound scan from the external inguinal ring to the upper segment of the epididymal head.
3. Fix the probe's view on the segment where the varicose veins are most prominent (Figure 2A) and click the ruler (distance) button to record the diameters of the veins on the right side (Figure 2B).
4. Similarly, examine the left side spermatic veins.
5. Instruct the patient to stand (Figure 3).
6. Using the same method, measure the diameter of the spermatic veins on both sides.
7. Press the Color Doppler ultrasound mode on the keyboard and turn on the Movie mode. Instruct the patient to take a Valsalva breath, select the red area on the screen, and record the venous reflux time (Figure 4).
8. For patients with a standing spermatic vein diameter of >2.8 mm and no evident reflux during the Valsalva maneuver, proceed with internal spermatic venography.
9. Disinfect the central vein of the left elbow with an alcohol cotton ball, and use a 5 mL syringe to ballistically inject 2.4 mL of contrast agent, followed by an injection of 5.0 mL of saline solution (Figure 5).
10. Turn to Contrast-Enhanced ultrasound mode. Instruct the patient to take a Valsalva breath, record images in a contrast-enhanced ultrasound mode, and record the duration of backflow (Figure 6).

Results

From June 2022 to June 2023, our institution conducted a total of 2,789 testicular vein ultrasound examinations. Among them, the positive detection rate for varicocele was 84.51%. Specifically, 24.35% of the patients had unilateral (left) varicocele, 2.34% had unilateral (right) varicocele, and 73.31% had bilateral varicocele. Notably, in the supine ultrasound examination (Figure 1), approximately 48.45% of the patients did not show varicose veins on the right side of the spermatic cord (

Discussion

With the intensification of research in the realm of male reproductive health in recent years, varicocele has been recognized as one of the primary factors affecting male fertility. Although its clinical manifestations are diverse, accurate and effective diagnosis remains a pivotal step in determining therapeutic outcomes. Physical examination (PE) is extremely important in screening for varicocele; a worm-like varicose vein at the base of the scrotum can be seen in severe varicocele patients, and for mild to moderate va...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Dianerkang Iodophor Skin Disinfectant	Shanghai Likang Disinfectant HI-Tech Co,Lid	31005102	For skin disinfection and the effective iodine content is from 4.5g/L~5.5g/L
Disposable dressing forceps	Jiaxing Zhongxin Medical Instrument Co., Ltd	MLD-01	Holding disinfectant cotton balls for disinfection
Physiological saline	Shanghai Kindly Medical Instruments Co., Ltd	2452161324	Used for injecting contrast agents
Shallow probe (high frequency)	General Electric Company	Voluson E6	Devices for transmitting and receiving ultrasonic waves
Sulfur hexafluoride microbubbles for injection	BRACCO INTERNATIONAL BV	SonoVue	Improve the ultrasound echo rate of blood, thereby improving the contrast between blood and surrounding tissues
Ultrasonic coupling agent	Shanghai Junkang Medical Equipment Co., Ltd	DS-1	Eliminate air gaps between the probe and the detected object, improve the transmission efficiency of ultrasound
Ultrasound diagnostic equipment	General Electric Company	Voluson E6	Process and display the signal received from the probe
Vein Detained Needle	Shanghai Kindly Medical Instruments Co., Ltd	60017202	Indwelling venous channels to reduce drug leakage and save time