**2. Clinical evaluation**

Children and adolescents suspected of having varicoceles should undergo a thorough assessment of their medical history, as well as a physical exam including an examination of the scrotum in the standing and supine position in a warm environment. The grading scale for varicoceles ranges from subclinical to grade III, depending on the severity, as depicted in **Table 1**. Subclinical varicoceles are only detected with ultrasound imaging. Dubin and Amelar developed a scale for varicocele comprising grades I through III in the early 1970s [1].

Grade I varicoceles are only palpable with Valsalva. Grade II varicoceles are visible with Valsalva pressure and palpable without Valsalva pressure, while grade III varicoceles are visible without Valsalva pressure and are historically correlated with the pathognomonic 'bag of worms' appearance. Depending on the scrotal skin thickness and room temperature, the 'bag of worms' is not always readily apparent even with grade III varicocele. In general, grade II and III varicoceles are readily identifiable by physical examination and are commonly referred to a urologist.

Testicular growth is typically considered to be inversely negatively affected by the varicocele grade. However, other studies have not observed a relationship. Therefore, some authors argue that the varicocele grade alone is not an indication for surgery in the majority of patients [5].

Testicular volumes can be more accurately assessed with ultrasound in pediatric patients rather than by physical examination alone, and serial ultrasound imaging can be utilized for active monitoring of the impact of varicocele on testicular growth. While ultrasound is a better method for accurate measurement of testicular volumes, an orchidometer is a reasonable alternative.

The development of US imaging and particularly the introduction of highfrequency probes associated with the color-Doppler US has led to widespread use of this diagnostic method in the search and characterization of varicocele. The examination evaluates the diameter of the venous vessels as well as colorimetric and blood flow changes.

The most commonly applied US classification systems are those proposed by Sarteschi et al. and Chiou et al. [6, 7].

The classification system proposed by Sarteschi et al. divides varicocele into five grades on the basis of color-Doppler US findings obtained with the patient at rest and during the Valsalva maneuver (**Table 1**). Other US classification systems comprise those proposed by Hoekstra, Hirsh, Oyen, and the recent system proposed by Iosa et al. [8, 9].

The testes of a normal patient should be symmetrical in size and consistency. An orchidometer can be a reliable device to assess testicular size, with good interobserver variability. However, compared with ultrasonography (US), it may lack sufficient accuracy to distinguish a testis volume differential of less than 50%.


**Table 1.** *Grades of varicocele.*

Two formulas are used to calculate testicular volume on the basis of dimensions obtained via US: the Lambert formula and the volume-of-rotational-ellipsoid formula. The Lambert formula is as follows:

• Testicular volume = Length × width × depth × 0.71

Two variations exist for the volume-of-rotational-ellipsoid formula:


Hsieh et al. studied the reliability of these formulas and found that the Lambert formula was more accurate than both of the volume-of-rotational-ellipsoid formulas and more precise than the second of the two volume-of-rotational-ellipsoid formulas.

A size difference of more than 3 cm3 is considered significant. The average volume of the male testis is 23 ± 3 cm3 [10–12].

A comprehensive analysis of US data on varicocele diagnosis is available from the review of Lotti et al. The authors indicate that there is no international consensus for the assessment of different ultrasonography parameters. An agreement between world societies would be useful in this case [13].
