Degrees of varicocele

• The degrees of varicocele depend directly on the severity and the ability to be diagnosed, and may be diagnosed with the naked eye or require additional tests.
• In addition to the classification of the grades of varicocele, within this classification, different types of varicocele can be detected.
• In the vast majority of cases, especially in the more advanced degrees of varicocele, surgical intervention is recommended to avoid major problems.

An anechoic mass (a medical term for an organic structure that does not form an acoustic shadow on ultrasound and usually indicates that the structure in question is not solid) of venous origin formed by stasis of blood from the surrounding venous network and belonging to the testicle, which we call the pampiniform plexus, is called a varicocele.

Do you need varicocele surgery?

Request a free and immediate appointment with our specialists in Urology

Make an appointment

Anatomically, varicocele is defined as a dilatation of the veins forming the pampiniform plexus. 

The pampiniform plexus is located adjacent to the testicle and is made up of 3 main groups of veins: anterior, posterior and middle. The venous blood leaving the pampiniform plexus drains directly into the spermatic vein which, depending on whether it is right or left, drains into the left renal vein or into the inferior vena cava if we are talking about the right spermatic vein.

The varicocele is usually located inside the scrotal sac and when the disease is advanced it usually presents as a lump or mass surrounding the testicle.

Varicocele is usually congenital or forms in adolescence, although there may be no symptoms until later in life. It is usually unilateral, affecting the left testicle 90% of the time, in 7% of cases it is usually bilateral and in 3% of cases it affects the right side.

Prevalence has been estimated at around 10-15% of the general population of men.

The clinical picture of a varicocele is very non-specific. In most cases the varicocele may go unnoticed or only be able to be palpated by valsalva manoeuvres. In other cases the symptoms associated with a varicocele may be pain or a feeling of heaviness when the size of the varicocele is moderately large.

Varicocele has an important relationship with infertility in the couple so that although only 10% of patients with varicocele may present infertility, 40% of men with reproductive difficulties have a varicocele, being the most frequent treatable cause of infertility in the male sex.

Varicocele as an expansive process of venous blood accumulation in the form of varicose veins or vascular nodules can be divided or classified into different degrees of varicocele. 

The different degrees of varicocele can be distributed according to multiple classifications. 

By worldwide consensus, the Dubin classification has been established as the international classification for defining the different grades of varicocele. This classification takes into account the palpation of the presence of varicocele or its size. 

The Dubin-Amelar grade classification is divided into 4 different grades:

• GRADE 0 OR SUBCLINICAL: corresponds to the presence of a varicocele in a male that can only be diagnosed by ultrasound, either doppler or normal testicular ultrasound, or by some other diagnostic imaging means.
• GRADE 1: degree of varicocele corresponding to the presence of a varicocele that is only palpable when the patient performs valsalva manoeuvres (manoeuvres that aim to increase intra-abdominal pressure, thereby raising venous pressure and promoting the appearance of varicocele).
• GRADE 2: corresponds to a degree of varicocele in which the doctor is able to palpate the presence of the venous varicose veins of the pampiniform plexus that define the varicocele without the need for the patient to perform Valsalva manoeuvres.
• GRADE 3: degree of varicocele in which the urologist or family doctor who is usually confronted with the diagnosis of this disease can visualise the varicocele without the need for palpation, only by direct visualisation.

In order to better understand the origin of varicocele formation and its different degrees, we will explain another type of classification from an anatomopathological point of view, which will help us to get an idea of the different types and degrees of varicocele according to macro and microscopic characteristics. 

For this idea we will base ourselves on the studies of Nistal-Regadera who classify the different degrees of varicocele into 3 fundamental ones:

• Spermatic varicocele: this is the grade of varicocele caused by the formation of varicose veins or accumulations of venous blood in the anterior part of the pampiniform plexus. This grade of varicocele is the most frequently encountered in clinical practice and corresponds to less advanced Dubin grades (grades 0, 1 and 2). These same scientists subdivide this grade of varicocele into two different types: diffuse spermatic varicocele (if the entire anterior pampiniform plexus is affected and completely surrounds the entire testicle) and focal spermatic varicocele (if only some portions of the anterior pampiniform plexus are affected, so that there are dilated veins and veins that are not dilated).
• Cremasteric varicocele: this is the grade of varicocele in which the lesion occurs in the posterior pampiniform plexus so that only the tail and the posterior part of the testicle are affected.
• Mixed varicocele: this is the grade of varicocele in which there are lesions of both the anterior plexus and the posterior pampiniform plexus. It usually appears in advanced stages of varicocele, usually corresponding to grade 3 according to Dubin's classification.

The usual treatment for varicocele is usually clinical, using protective and restraining measures, as in the vast majority of cases it does not usually produce significant symptoms that could affect the patient's day-to-day life. 

However, if the patient has fertility problems or any of the manifestations mentioned above, such as pain, heaviness or testicular atrophy, then the only really effective solution to definitively cure the varicocele is surgery.

Do you need varicocele surgery?

Request a free and immediate appointment with our specialists in Urology

Make an appointment

The indications for surgical intervention of a varicocele are very clear and are present in all urological clinical guidelines that study varicocele. 

The indications are: testicular pain due to the presence of the varicocele, the presence of a grade 3 varicocele in the consultation of a urologist or primary care physician even if it is not painful, if we are in the presence of testicular atrophy secondary to a varicocele (defined as less than 2 cm in diameter), when it is bilateral or when the varicocele is in a patient of any age, although they will generally be patients of adolescent age, who present alterations in their spermiogram or are being studied for fertility problems.

Infertility is defined as the difficulty of a man and a woman to conceive during a period of one year without the use of contraceptive methods.

As methods of surgical intervention for the degrees of varicocele mentioned above, there are basically four types of intervention, of which the most prevalent and those with the best success rates are open surgery and inguinal microsurgery with 4x magnification glasses. In both cases the process is simple and the rate of recurrence and surgical complications is very low.