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Color Doppler Ultrasound (CDU) classification of varicocele

Grade 1 is characterised by the detection of a prolonged reflux in vessels in the inguinal


channel only during Valsalvas manoeuvre, while scrotal varicosity is not evident in the
previous grey-scale study.
Grade 2 is characterized by a small posterior varicosity that reaches the superior pole of
the testis and whose diameter increases after Valsalvas manoeuvre. The CDU evaluation
clearly demonstrates the presence of a venous reflux in the supratesticular region only
during Valsalvas manoeuvre.
Grade 3 is characterised by vessels that appear enlarged to the inferior pole of the testis
when the patient is evaluated in a standing position, while no ectasia is detected if the
examination is performed in a supine position. CDU demonstrates a clear reflux only
under Valsalvas manoeuvre.
Grade 4 is diagnosed if vessels appear enlarged, even if the patient is studied in a supine
position; dilatation increases in an upright position and during Valsalvas manoeuvre.
Enhancement of the venous reflux after Valsalvas manoeuvre is the criteria that allows
the distinction between this grade from the previous and the next one. Hypotrophy of the
testis is common at this stage.
Grade 5 is characterised by an evident venous ectasia even in an upright position. CDU
demonstrates the presence of an important basal venous reflux that does not increase after
Valsalvas manoeuvre.

Scoring System for Color Doppler Ultrasound (CDU) Diagnosis of Varicocele
Score
Maximum vein diameter (mm)
<2.5 0
2.5-2.9
3.0-3.9
>/= 4.0

0
1
2
3
Plexus/sum of diameter of veins
No plexus identified
Plexus (+) with sum diameter <3 mm
Plexus [+) with sum diameter 3-5.9 mm
Plexus (+) with sum diameter >/=6 mm

0
1
2
3
Change of flow velocity on Valsalva maneuver
<2 cm/s or duration <1 second

0
2-4.9
5-9.9
>/=10
1
2
3
Total score 0-9

A total score of 4 or more determines the presence of a varicocele by CDU.


References
1. Chiou RK, Anderson JC, Wobig RK, Rosinsky DE, Matamoros A Jr, Chen WS, Taylor
RJ. Color Doppler ultrasound criteria to diagnose varicoceles: correlation of a new
scoring system with physical examination. Urology. 1997 Dec;50(6):953-6. [Medline]
2. Liguori G, Trombetta C, Garaffa G, Bucci S, Gattuccio I, Salam L, Belgrano E. Color
Doppler ultrasound investigation of varicocele. World J Urol. 2004 Nov;22(5):378-
81.[Medline]