Provocative measures in the sonographic evaluation of varicocele in obese patients and relation of different grades of varicocele with intra-testicular hemodynamics

Abstract Background Doppler ultrasonography is typically used to diagnose as a non-invasive imaging technique for the evaluation of varicocele. The Valsalva maneuver and standing position cause reflux of blood through incompetent venous valves, aiding in identifying the varicocele. Varicocele also compromises blood return and leads to an increase in intratesticular artery resistance and pulsatility. However, the efficacy of the standing position Valsalva maneuver and intratesticular artery resistance and pulsatility indices in obese patients for diagnosing varicocele remains uncertain. Obesity presents unique challenges during sonography due to increased adipose tissue and altered venous hemodynamics. Objective To evaluate the effect of standing position and Valsalva maneuver on the sonographic diagnosis of varicocele in obese patients and the relation of different grades of varicocele with intratesticular hemodynamics. Methods This cross-sectional study was conducted at Gilani Ultrasound Centre, Lahore, Pakistan, from March 2019 to October 2023 on 107 obese male patients, and comprised aged 20–45 years diagnosed with varicocele and infertility having varicocele. Patients with testicular surgery, anomalous genitalia, lower limb edema, abdominal ascites or pleural effusion were excluded. Results The mean age of 30.16 ± 3.62 (23 to 39) years. The mean of BMI was 34.51 ± 2.09 (30 to 40), 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. The mean of right-sided intratesticular artery resistive index was 0.63 ± 0.07 (0.49 to 0.88), while the mean of left-sided intratesticular artery resistive index was 0.67 ± 0.07 (0.50 to 0.92). Conclusion A significant impact of the provocative measures like standing position and Valsalva maneuver is observed on the sonographic diagnosis of varicocele and statically significant increases in the intratesticular artery resistive and pulsatility indices were noted.