Diagnostic accuracy of physical examination compared with color Doppler ultrasound in the determination of varicocele diagnosis and grading: Impact of urologists’ experience

Abstract

Background Treatment of palpable varicocele in infertile men with abnormal semen parameters is widely accepted, and physical examination (PE) remains a cornerstone for recommending varicocele repair. However, identification of clinical varicocele during PE can be challenging for both urology residents and consultants. Objective To compare the diagnostic accuracy of PE to color Doppler ultrasonography (CDU) for the diagnosis of varicocele in experienced and non‐experienced examiners. Materials and methods Diagnostic accuracy study involving 78 patients attending a university‐based infertility unit. Patients underwent scrotal PE by both experienced (over 10 years experience in male infertility) and non‐experienced urologists (senior residents), and were subjected to CDU. varicocele diagnosis and varicocele grading were compared between examiner groups and to CDU. Accuracy measures were evaluated, and interobserver agreement was estimated using unweighted kappa statistics. A subgroup analysis for normal and high body mass index (BMI) was also performed for the same variables. Results Accuracy of PE for varicocele diagnosis was 63.5% with a positive predictive value (PPV) of 75.5%. The specificity and PPV of PE were higher among experienced than non‐experienced urologists (82.0% CI: 74.27‐88.26 and 81.1% CI: 74.39‐86.44% vs 67.2% CI: 58.33‐75.22 and 70.6% CI: 64.52‐76.08, respectively). Agreements on varicocele diagnosis (k: 0.625 vs 0.517) and grading (k: 0.548 vs 0.418) by PE were higher among experienced than non‐experienced urologists. Differences between eutrophic and overweight/obese patients were also suggested. Discussion and conclusions PE performed by infertility specialists identify patients with varicocele more precisely than non‐specialists. However, PE alone has suboptimal accuracy for varicocele diagnosis. Our results indicate that PE should be followed by CDU to decrease the number of false positives and increase the diagnostic accuracy of varicocele diagnosis.

Differential Diagnosis of Azoospermia in Men with Infertility

“…Assessment of the spermatic cord is mandatory as a varicocele may be found [5,11,21]. Varicocele is a prevalent congenital abnormality linked to infertility, impaired testicular growth, and hypogonadism [22][23][24][25].…”

“…As a general rule, men with suspected NOA-STF should undergo scrotal ultrasonography because these patients have an increased chance of testicular cancer [ 30 ]. A scrotal scan may also help to determine testis volume, epididymis characteristics, and presence of a varicocele if a physical examination is inconclusive (e.g., large hydrocele, inguinal testis, obesity) [ 11 , 21 ]. Additionally, indirect signs of obstruction might be seen during a scrotal US examination, including a dilated rete testis, enlarged epididymis, or absent/partially absent epididymis in patients with CBAVD [ 59 ].…”

The obesity paradox in varicocele – is the protective effect real?

“…On the other hand, what every urologist with expertise in male infertility does know is that obesity may affect the ability to make the varicocele diagnosis accurately using physical examination alone. Not only that, but there is a remarkable inter-operator variation in varicocele diagnosis by physical examination (12). In a recent study involving 78 patients, we found that the specificity and positive predictive value of physical examination were higher among experienced (male infertility experts) than in-training urologists (82.0% and 81.1% versus 67.2% and 70.6%).…”

The Comparison of Resistance Index of Testicular Artery Using Color Doppler Ultrasound in Infertile Men Undergoing Varicocelectomy

“…The golden standard for diagnosis of varicocele is based on clinical examinations which are divided into 3 grades; grade 1 varicocele is touchable only during valsalva maneuver, grade 2 is easily touchable without valsalva maneuver, and grade 3 could be observed without any touching ( 8 , 9 ). Imaging studies also play pivotal roles in the diagnosis and staging the varicocele.…”