[Downloaded free from http://www.njcponline.com on Monday, July 6, 2020, IP: 197.90.36.231] Original Article Ultrasound Evaluation of Testicular Vein Diameter in Suspected Cases of Varicocele: Comparison of Measurements in Supine and Upright Positions UR Ebubedike, SU Enukegwu1, AM Nwofor2 Department of Radiology, Background: Scrotal ultrasonography has high sensitivity in the detection Nnamdi Azikiwe University of intra‑scrotal abnormalities. Various ultrasonographic parameters such as Teaching Hospital, NAUTH Nnewi, 1St Bridget’s the spermatic cord diameter, venous diameter, and venous retrograde flow in Xray Centre Benin City, either supine or upright positions with or without Valsalva maneuver have been 2Depatment of Surgery, Abstract investigated to assess patients suspected of having varicocele. Aims: This study Nnamdi Azikiwe University aimed at comparing testicular vein diameter in supine and upright positions using Teaching Hospital, NAUTH, ultrasonography. Methodology: This is a prospective multicenter study conducted Nnewi, Nigeria between September 2018 and June 2019. Eighty‑two consenting suspected cases of varicocele, 20 years and above, referred for scrotal ultrasonography were included in this study. Results: The study population had a mean age of 42.9 + 14.89 (SD) with a range of 20–96 years. The highest number of participants fell within the age range of 30–39 years 23 (28%). Varicocele was demonstrated in 96.3% of the patients. More patients showed sonographic evidence of varicocele in the upright position, on the right 50 (61%) as well as left 50 (61%). Bilateral varicocele had a higher frequency in the upright position 45 (54.9%), while supine was 23 (28%). Upright position had the widest diameter in 72% of participants on the right and 82% on the left. The upright position also showed higher average vein diameter of Received: 23-Oct-2019; 2.6 mm and 2.9 mm on the right and left, respectively, while it was 2.2 mm and Revision: 2.3 mm for right and left in the supine position. Conclusion: The upright position 16-Feb-2020; is more predictive of varicocele in scrotal ultrasound examination for suspected Accepted: cases of varicocele. We recommend an upright position where one position is to 15-Apr-2020; be used. Published: 03-Jul-2020 Keywords: Scanning positions, scrotal ultrasound, testicular vein, varicocele Introduction it is an imaging modality of choice in differentiating testicular from para‑testicular lesions in adults and he role of ultrasound evaluation of scrotal [2‑4] T pathologies as well as its availability has made children. sonography a primary diagnostic tool.[1] Other imaging Varicocele is a common abnormality characterized by modalities which can be used to evaluate scrotal retrograde blood flow in the internal spermatic vein. pathologies include CT, MRI, and angiography. The This abnormal flow is caused by incompetence or use of ionizing radiation, high cost, and unavailability absence of venous valves.[5] Varicocele has been found make them inaccessible in resources poor societies like in approximately 15% of the general population and in Nigeria, whereas ultrasonography is readily available, cheap, and noninvasive and uses nonionizing Address for correspondence: Dr. UR Ebubedike, Department of Radiology, Nnamdi Azikiwe University Teaching radiation. Scrotal ultrasonography has high sensitivity Hospital, NAUTH Nnewi, Nigeria. in the detection of intra‑scrotal abnormalities[2] and E‑mail:[email protected] Access this article online This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows Quick Response Code: Website: www.njcponline.com others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. DOI: 10.4103/njcp.njcp_579_19 For reprints contact: [email protected] How to cite this article: Ebubedike UR, Enukegwu SU, Nwofor AM. Ultrasound evaluation of testicular vein diameter in suspected cases of PMID: ******* varicocele: Comparison of measurements in supine and upright positions. Niger J Clin Pract 2020;23:1004-7. 1004 © 2020 Nigerian Journal of Clinical Practice | Published by Wolters Kluwer - Medknow [Downloaded free from http://www.njcponline.com on Monday, July 6, 2020, IP: 197.90.36.231] Ebubedike, et al.: Ultrasonic measurement of testicular vein diameter 20%–40% of infertile men.[6‑8] The clinical diagnosis of were examined sequentially along the course of varicocele is routinely made by physical examination in the proximal genital tract but with emphasis on the a warm environment. However, various ultrasonographic measurement of widest vein (pampiniform plexus) parameters such as the spermatic cord diameter, venous diameter at the level of the epididymal head using diameter, and venous retrograde flow in either supine B‑Mode. or upright positions with or without Valsalva maneuver Data analysis have been investigated to assess patients suspected of Statistical analysis of the data was done using the having varicocele.[9‑12] statistical package for the social science (SPSS) software The first part of the examination is the B mode version 21.0 for windows. evaluation which allows a demonstration of the presence of enlarged venous structures. Different Results authors use different criteria for defining a varicocele The study population had a mean age of [8‑10] detected ultrasonographically. However, there 42.9 ± 14.89 (SD) with a range of 20–96 years. Figure 1 are no generally accepted criteria for the diagnosis shows that the highest number of participants fell within [8] of varicocele by this method. The diagnosis of the age range of 30–39 years 23 (28%), while the least varicocele can be made with detection of vessels age frequency was 1 (1.2%) for 60 to 69 years, also [8] [13] larger than 3 mm; however, Gonda et al. reported for 80 years and above. Varicocele was demonstrated that ultrasound has a 95% sensitivity for the detection in 96.3% of the patients. Table 1 shows the number of of a varicocele using a 2 mm cut off for vein diameter. participants with varicocele in the supine and upright Several authors have examined groups of patients to position for the left and right as well as bilateral. More establish qualitative and quantitative color Doppler patients showed sonographic evidence of varicocele in ultrasound (CDU) criteria but the criteria were the upright position 50 (61%) on the right and 50 (61%) [14‑16] heterogeneous and poorly defined. Some studies on the left. In addition, bilateral varicocele had a higher also examined patients using color Doppler in supine frequency in the upright position 45 (54.9%), while position, while others did so for patients in standing supine was 23 (28%). The average vein diameter in [14,16‑22] position. Some have also compared vein supine position on the right was 2.2 mm with a range measurement in either position with/without Valsalva of 1–3.8 mm, while it was 2.3 mm on the left with a [21] maneuver. Measurement of testicular vein diameter range of 1–4.3 mm. The average vein diameter in is usually done in supine position in our environment. upright position on the right was 2.6 mm with a range In this study, we compared vein diameter measurement of 1–4.8 mm, while it was 2.9 mm on the left with a in supine and upright positions. range of 1.3–5.3 mm. On the right, upright position had the widest diameter in 72% of participants and on the Methodology left, it was 82%. This is a prospective multicenter study conducted between September 2018 and June 2019. Eighty‑two There was positive correlation between the measurements consenting suspected cases of varicocele, 20 years of the vein diameter in the supine and upright positions and above, referred for scrotal ultrasonography were for the right and left, respectively (Pearson’s correlation, included in this study. Patients with previous scrotal r > 0). It was low on the right, r = 0.274 (r < 0.3) and surgery were excluded. For confidentially, patients were moderate on the left, r = 0.698 (r = 0.3 to 0.7). There assigned numbers. They were also free to withdraw from was no high (r > 0.7) or perfect correlation (r = 1). the study at any time. Figures 2 and 3 are scatter plots showing the pictorial representation of the correlation. These patients were scanned by two radiologists in both supine and upright positions using two ultrasound scanners: an Aloka Prosound SSD–2500 Table 1: Different Ultrasound scan positions and frequency of varicocele (n=227) SX machine and a CHISON digital ultrasound system Position Frequency Percentage Model Ivis 60, both having linear transducer (freq. 7.5 Supine(R) 25 30.5 MHZ) and color Doppler capability. The examination Supine(L) 34 41.5 was performed in a warm room. While in supine Upright(R) 50 61.0 position, the penis rests on the lower abdomen and Upright(L) 50 61.0 scrotum is supported by a towel between the thighs. Supine(Bilateral) 23 28.0 The scrotal contents, i.e., testes, para‑testicular area, Upright(Bilateral) 45 54.9 mediastinum testes, epididymal head, body, and tail, (R‑right, L‑left) NigerianNigerian Journal Journal of Clinical of Clinical Practice Practice ¦ Volume ¦ Volume XX ¦23 Issue ¦ Issue XX 7¦ Month¦ July 2020 1005 [Downloaded free from http://www.njcponline.com on Monday, July 6, 2020, IP: 197.90.36.231] Ebubedike, et al.: Ultrasonic measurement of testicular vein diameter 30 the position for measurement of testicular vein diameter, level of measurement as well as Cut‑off point of vein 25 diameter. Most of the patients were in their fourth and fifth decade of life in agreement with the work [23] 20 FREQUENCY of Elkhadir et al. These age groups accounted for % 53.6% of the studied population; this is higher than the [23] 15 44% recorded by Elkhadir et al.