The compromise of blood return from the testes and scrotum leads to the dilatation of and tortuosity of the veins in the pampiniform plexus and epididymis which is termed as varicocele. When the blood is pooled in the venous system and return is ceased then theoretically the arterial blood flow resistance is increased. Apart from that, the patient posture and Valsalva maneuver also affect the blood return and eventually the arterial blood flow resistance. To look for its practical impact 107 patients were purposively included in this study the mean age of the patients was 30.16 ± 3.62 (23 to 39) years. In a similar study 87 individuals were included to establish the effect of Valsalva maneuver and examination of patient in standing position on varicocele(20) as shown in (Fig. 2) In another study 492 individuals were included to find the prevalence of varicocele in a population usually shifting between sea level and high altitude. Valsalva maneuver was used to evaluate varicocele with sonography.(21) In a study 449 males were included to establish the role of standing for the sonographic evaluation of varicocele while accounting for different clinical outcomes. Participants were selected for the study after completion of their ultrasound to help in the management of varicocele.(22)
Left side was found more susceptible to develop varicocele as compared to right side. According to the findings of the current study; bilateral varicocele were observed in 35 (32.7%), right sided varicocele were seen in 6 (5.6%).and left sided varicocele were seen in 66 (61.7%). In this context a number of studies were conducted while revealing that left side is more prone to develop varicocele as compared to right side. It was justified by a number of studies that the left testicular vein is drained to the left renal vein and thence to the IVC. Due to long path and compression due to excessive subcutaneous fats and intestinal mass the left sided blood return is compromised. However left side develops more varicocele.(23, 24, 25) In the current study most of the varicocele were Grade I 53 (49.53%), followed by Grade II which was found in 43 (40.19%) individuals while grade III varicocele was least common and found in 11 (10.28%) individuals. Similarly, in the findings of a study grade I was seen in 9%, grade II 53%, and grade III 38% of the participants.(19, 20)
In the current study it was seen that standing position and Valsalva maneuver has a great impact on the diagnosis of particularly subtle varicocele like grade I and grade II. the mean of right sided varicose veins diameter in laying position was 2.16 ± 0.75 (0.8 to 5.1)mm, while the mean of right sided varicose veins diameter in standing position was 2.5 ± 0.86 (1.1 to 6.0)mm, and the mean of left sided varicose veins diameter in laying position was 2.63 ± 0.68 (0.9 to 5.5)mm, while the mean of left sided varicose veins diameter in standing position was 3.11 ± 0.75 (1.3 to 6.4)mm. It is therefore recommended that standing position and Valsalva maneuver should be used as provocative measures for the evaluation of varicocele. Similar findings were seen in a study to determine the region and position for the measurement of varicocele 35 patients were included. The mean diameter of the varicose veins were recorded in laying and standing position at the sub- inguinal region as lying posture 2.94mm and 3.29mm respectively. In the peri testicular region in laying and standing position the mean vein diameters were 3.31mm and 3.65mm respectively.(26) In the current study all the participants were obese, because it is considered that obesity is one of the potential causes of varicocele. In a similar study to determine the interdependence of BMI and diameter of the spermatic vein, 114 patients were included. Amongst all the participants 46 were with normal BMI, 54 were overweight and 14 were obese.(27) The left testicular volume in normal was 16.1cc in overweight was 14.7cc and 12.8cc in overweight. In the current study the testicular volume was reduced in the same fashion. In the study mentioned above the spermatic vein diameter in laying position 2.58 mm in normal weight individuals but in overweight it was 2.77mm and in obese the mean spermatic vein diameter was 3.19mm. In laying position with Valsalva the mean spermatic vein diameter in normal weighted individuals was 2.82mm, in overweight it was 3.04mm and in obese the mean vein diameter was 3.51mm. While in standing position the mean vein diameter in normal weighted was 2.90mm, in overweight the mean diameter was 3.01mm and in obese the mean vein diameter was 3.37mm. But in standing position with Valsalva the mean vein diameter in normal weight men was 3.17mm, in overweight it was 3.28mm and in obese it was 3.59mm.(24, 27)
In the current study, grade I right side with laying and standing positions the diameter of the varicose veins were 1.97mm and 2.29mm respectively, while on the left side 2.24mm and 2.68mm respectively, similarly in grade II the mean vein diameter on right side in lying and standing were 1.98mm and 2.31mm respectively, while 2.73mm and 3.23mm on the left side in lying and standing position respectively. In grade III right side with laying and standing positions the diameter of the varicose veins were 3.85mm and 4.44mm on the right side respectively, while on the left side were 4.09mm and 4.75mm on the left side respectively. In a study it was observed that the mean diameter of varicose vein in laying position was 1.8 mm in grade I, 2.1 mm in grade II, and 2.6 mm in grades III, however 1.2mm in normal testis. In laying position with only Valsalva maneuver the mean venous diameter was 3.0 mm in grade I, 3.4 mm in Grade II, and 4.2 mm in grade III varicocele whereas 1.8 mm in normal. Average of resting-Valsalva ratio in the supine position was 0.72.9. In the standing position without Valsalva, mean venous diameters were 2.8 mm, 3.3 mm, 3.8 mm (grades I, II, III) and 1.8 mm for normal. With both Valsalva maneuver and the standing position, the mean venous diameters were 5.0 mm, 5.8 mm, 6.6 mm in grades I, II, III respectively and 2.5 mm in normal.(20)
Testicular artery pulsatility index (PI) was included in the current study as an additional parameter. In grade I varicocele the mean PI of the right intratesticular artery was 1.27 as shown in (Fig. 3). In grade II varicocele the mean PI of the right intratesticular artery was 1.56. While in grade III varicocele the mean PI of the right intratesticular artery was 2.58. On the left side in grade I varicocele the mean PI of the intratesticular artery was 1.48. In grade II varicocele the mean PI of the left intratesticular artery was 1.63 as shown in (Fig. 4). While In grade III varicocele the mean PI of the left intratesticular artery was 2.63 as shown in (Fig. 5). In a similar study to investigate difference in intra-testicular arterial pulsatility index (PI) and resistance index (RI) between varicocele and healthy testes with the help of Doppler sonography. It was observed that there was no significant difference on the right side but statistically significant difference in the PI and RI of left intratesticular artery was observed.(28)