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

Provocative measures in the sonographic evaluation of varicocele in obese patients and relation of different grades of varicocele with intra-testicular hemodynamics | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Provocative measures in the sonographic evaluation of varicocele in obese patients and relation of different grades of varicocele with intra-testicular hemodynamics Zain ul Hasan, Syed Amir Gilani, Asif Hanif, Raham Bacha, Zareen Fatima This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4353185/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version 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. Obesity Valsalva maneuver Male infertility Varicocele Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Varicoceles is the dilation and tortuosity of testicular drainage in the epididymis and pampiniform plexus in the spermatic cord. ( 1 ) As blood stays for long time in the veins causing territorial increase in the temperature. ( 2 ) Sperms cells are very sensitive to a minimal increase in temperature, therefore, dead sperm cells increases in the semen sample instead of active and motile ones needed for fertilization. ( 3 , 4 ) Secondly engorgement of the testicular venous system can lead to increase in blood flow resistance. ( 5 ) These dilated and tortuous veins in pampiniform plexus of gonadal veins above the testicle, are the leading correctible cause of male-factor infertility. ( 6 ) It is found in 30–40% of men with primary infertility and 51–77% of men with secondary infertility. ( 7 , 8 ) Varicoceles reduce sperm quantity and quality, it can also effects testicular development in adolescents, cause pain and can decrease testosterone levels. ( 9 ) Physical examination is the standard diagnostic method for varicocele, but usually difficult to estimate the existence of varicocele by use of physical examination alone. Mild varicoceles are impalpable and asymptomatic and are diagnosed only with ultrasound evaluation owing to thick scrotal skin and a strong cremasteric reflex. ( 10 ) Doppler Ultrasonography is a non-invasive imaging technique and is highly sensitive in detecting blood flow abnormalities, including retrograde blood flow characteristic of varicoceles and aiding in the diagnosis and grading of varicoceles. ( 11 ) While scrotal ultrasonography is the gold standard for diagnosing varicoceles, but it may not always provide conclusive results. ( 12 ) Factors such as operator’s experience, technique, equipment quality, and patient anatomy especially obesity can affect the accuracy of sonographic imaging. ( 13 ) During Doppler sonography severe and moderate varicoceles are easy to identify, but mild varicoceles are difficult to diagnose specially in obese patients. ( 14 ) Therefore, the role of scrotal Doppler sonography with provocative measures like Valsalva maneuver and standing position is essential for the interpretation of an indecisive scrotal examination. ( 15 ) In the standing positions the blood is pulled towards the center of gravity by the gravitational force. However more force is required for it to return to the heart and in most of the cases the blood is pooled in the peripheral veins. ( 16 ) The persistence blood pooling in the peripheral veins leading to varicocele in the standing position but spontaneously subsides in the lying position. In usual, the testicular sonography is performed in supine laying position wherein the minimal varicocele subsides, and the sonographic findings yield false negative results. ( 17 ) Similarly, during Valsalva maneuver the abdominal IVC is compressed, and the blood return is ceased leading to the peripheral blood pooling. However, with the used of this maneuver the minimal varicosity will be reliably evaluated, but more cooperation is needed from the patient which is practically impossible in most of the patients. ( 12 ) In general, sonography of every structure but particularly the diagnosis of varicocele is a challenging task in obese individuals. In obese individuals the veins are compressed by the excessive bulk of subcutaneous fats and minimal varicocele is missed. Secondly the excessive accumulation of subcutaneous fats are difficult to be penetrated by the ultrasound to image the deep varicocele. ( 5 ) Grayscale ultrasound along with Doppler capability is not only important for the identifications and measurements of the testicular venous drainage but it is also used to measure the hemodynamic parameters like peak systolic velocity, end-diastolic velocity, Resistive index, pulsatility index and other detailed characteristics. ( 11 ) It was there for intended in the current study to evaluate the impact of Valsalva maneuver and standing position in the detection of varicoceles using color Doppler sonography. Additionally, it is aimed, if the provocative measures standing position and Valsalva were proved to affect the varicocele and hemodynamic changes in the testicular arteries then these parameters will be incorporated in the current sonographic criteria of varicoceles, specifically focusing on obese patients. If the varicocele is diagnosed timely then the varicocele related male infertility could properly be managed. Material and Methods This cross-sectional study was conducted at Gilani Ultrasound Center, Lahore, Pakistan from March 2020 to October 2023 while including 107 infertile obese patients after approval of Institutional Research Ethical Committee, the University of Lahore. However, those with any clinical evidence of infertility in their spouses or with previous history of testicular trauma or surgery, Patients with anomalous genitalia, lower limb edema, abdominal ascites or pleural effusion were excluded from the study. Sonographic Technique: Toshiba Xario equipped with the linear transducer having frequency range 7–14 MHZ was used. Gray scale, color, power, and pulsed Doppler were used for the scanning of patients. American Institute of Ultrasound in Medicine (AIUM) guidelines for the scrotal ultrasound were followed. ( 18 ) Patients were positioned supine and instructed to undress from the waist down, lying on an examination table for the assessment. A towel or sheet was used to cover the patient's body for privacy. The scrotum was placed on an appropriate support and distended. The latter was accomplished by having the patient exert moderate upward traction on the penis (toward the umbilicus). A water-based gel was applied to the scrotal area and the transducer was moved gently over the scrotal area. Special attention was given to pampiniform plexus, and the vein diameter was measured on gray scale on both sides. Color Doppler Ultrasound assessments were made under basal (resting) conditions then during the Valsalva maneuver. Then the patient was advised to stand and the evaluation was repeated with the same Valsalva maneuver. Color Doppler parameters were optimized for the evaluation of slow flow. ( 11 ) Lower scale of about 3cm/s was selected with wall filter at minimum levels, gain at the maximum level permitted by the presence of artifacts, elective focus on the region of interest) and standardized. The blood flow direction with Valsalva and normal respiration was observed on the grayscale and color Doppler to observe the reflux of blood. The findings of vein diameter more than 2.5 mm and blood flow reflux were considered to be suggestive of varicocele. Statistical Analysis: Statistical Package for the Social Sciences (SPSS) version 24 (SPSS 24, IBM, Armonk, NY, United States of America) was used for the analysis of data. Mean and standard deviation of the demographic parameters of the sample were documented. Comparison of the means of the age, BMI, right sided varicose veins diameter in laying position, right sided varicose veins diameter in standing position, left sided varicose veins diameter in laying position, left sided varicose veins diameter in standing position, right sided intratesticular artery resistive index and pulsatility index, left sided intratesticular artery resistive index and pulsatility index, right sided testicular volume and left sided testicular volume in various grades of varicocele were documented. The statistical significance of the means in various grades of varicocele were calculated with the help of one way ANOVA. Results Total 107 patients were included in this study with 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). The mean of right sided intratesticular artery pulsatility index was 1.52 ± 0.46 (0.88 to 3.11), while the mean of left sided intratesticular artery pulsatility index was 1.65 ± 0.44 (0.82 to 3.20). The mean of right testicular volume was 16.07 ± 2.2 (12 to 23.1) cc, and the mean of left testicular volume was 12.93 ± 1.9 (12 to 23.4)cc. The testicular parenchyma of 4 (3.7 %) was hypoechoic, while it was hyperechoic in 103 (96.3 %). Bilateral varicocele were observed in 35 (32.7 %), riht sided varicocele were seen in 6 (5.6 %).and leftsided varicocele were seen in 66 (61.7%). Grade 1 varicocele was seen in 53 (49.53%), Grade 2 in 43 (40.19%) and grade 3 in 11 (10.28%) individuals as shown in the graph (Fig. 1). In most of the individuals the BMI was ranging from 32 to 36 as you can see BMI 32 in 13 (12.1%) 33 in 17 (15.9%), 34 in 19 (17.8%), 35 in 17 (15.9%) and 36 in 23 (21.5%), but above and below this range there were only single or 2 individuals were observed maximum 40 BMI. Comparison of the means of the age, BMI, right sided varicose veins diameter in laying position, right sided varicose veins diameter in standing position, left sided varicose veins diameter in laying position, left sided varicose veins diameter in standing position, right sided intratesticular artery resistive index, left sided intratesticular artery resistive index. Right sided testicular volume and left sided testicular volume in various grades of varicocele are shown in the adjacent table. (Table 1 ) Table 1 Mean with standard deviation and p-value of the Rt Intratesticular PI, Lt Intratesticular PI, Rt Intratesticular RI, Lt Intratesticular RI, Rt Varicose veins diameter in lying position, Rt Varicose veins diameter in standing position, Lt Varicose veins diameter in lying position, Lt Varicose veins diameter in standing position, Rt Testicular Volume, Lt Testicular Volume in various grades of varicocele. Mean with standard deviation Grade-I (N = 53) Grade-II (N = 44) Grade-III (N = 10) p-value Rt Intratesticular PI 1.27 ± 0.26 1.56 ± 0.26 2.58 ± 0.23 0.000 Lt Intratesticular PI 1.48 ± 0.24 1.61 ± 0.32 2.63 ± 0.36 0.000 Rt Intratesticular RI 0.62 ± 0.05 0.6 ± 0.06 0.79 ± 0.07 0.000 Lt Intratesticular RI 0.63 ± 0.05 0.68 ± 0.05 0.82 ± 0.08 0.000 Rt Varicose veins diameter in lying position 1.97 ± 0.46 1.98 ± 0.55 3.85 ± 0.76 0.000 Rt Varicose veins diameter in standing position 2.29 ± 0.46 2.31 ± 0.61 4.44 ± 0.88 0.000 Lt Varicose veins diameter in lying position 2.24 ± 0.33 2.73 ± 0.43 4.09 ± 0.72 0.000 Lt Varicose veins diameter in standing position 2.68 ± 0.30 3.23 ± 0.44 4.75 ± 0.82 0.000 Rt Testicular Volume 16.89 ± 1.98 15.70 ± 2.18 13.63 ± 1.33 0.000 Lt Testicular Volume 16.35 ± 1.97 15.86 ± 1.62 14.25 ± 2.14 0.04 BMI 34.13 ± 1.665 34.64 ± 2.431 36.00 ± 2.055 0.000 One way ANOVA test was applied to know the relationship of age, BMI, right sided varicose veins diameter in laying position, right sided varicose veins diameter in standing position, left sided varicose veins diameter in laying position, left sided varicose veins diameter in standing position, right sided intratesticular artery resistive index, left sided intratesticular artery resistive index. Right sided testicular volume and left sided testicular volume with various grades of varicocele. Statistically there was no relationship between patient age and grades of varicocele with p-value of 0.67. Statistically significant relation was seen in BMI with grades of varicocele having a p-value of 0.03. Amongst grades of varicocele and right sided varicose veins diameter in laying position, right sided varicose veins diameter in standing position, left sided varicose veins diameter in laying position, left sided varicose veins diameter in standing position, right sided intratesticular artery resistive index, left sided intratesticular artery resistive index. Right sided testicular volume and left sided testicular volume with various grades of varicocele, statistically very strong relationship is observed with p-value less than 0.05 for each. Discussion 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 ) Conclusion Significant impact of the provocative measures like standing position and Valsalva maneuver is observe on the sonographic diagnosis of varicocele and statically significant increases in the intratesticular artery resistive and pulsatility indices was noted. Declarations Author Contribution 1- Zain ul Hasan (Corresponding author) MAIN AUTHOR2- Syed Amir Gilani (Co- author)3- Asif Hanif (Analyses)4- Raham Bacha (Data collection)5- Zareen Fatima (Proof reading) References da Silva HVN, Meller RL, Ogundipe EA, Rochon PJ, editors. Varicoceles: overview of treatment from a radiologic and surgical perspective. Seminars in Interventional Radiology; 2022: Thieme Medical Publishers, Inc. Comby P-O, Guillen K, Chevallier O, Lenfant M, Pellegrinelli J, Falvo N, et al. Endovascular use of cyanoacrylate-lipiodol mixture for peripheral embolization: Properties, techniques, pitfalls, and applications. Journal of Clinical Medicine. 2021;10(19):4320. Al-Nawab NAA, Ali IH, Al-Khafaji LKJ. The special techniques for Semen analysis and preparation. Research Journal of Pharmacy and Technology. 2021;14(9):4941-6. Shahat A, Rizzoto G, Kastelic J. Amelioration of heat stress-induced damage to testes and sperm quality. Theriogenology. 2020;158:84-96. 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Hasan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYDACZuYGBgYDEIOB8QEDwwFitDDCtTAbEKeFAaQFAtgkiNIi787Y+LmggMGev533WDVPzR05fgbmh49u4NFieJixWXqGAQOzxGG+tNs8x54ZSzawGRvn4NPSzNggzWPAwMZwmMfsNg/b4cQNB3jYpAloaf4N1MIjD9RSzPOPCC3yzIxtIFskDIBamHnbiNBiANRiDdRiYHiYx1hybt9hY8lmAn6R7z98+DbPHwZ7ufNnDD+8+XZYjp+9+eFjvLYcAFP/wSQTD4hkxqMcbEsDEofxBwHVo2AUjIJRMDIBAMxRQfW17NNYAAAAAElFTkSuQmCC","orcid":"","institution":"The University of Lahore","correspondingAuthor":true,"prefix":"","firstName":"Zain","middleName":"ul","lastName":"Hasan","suffix":""},{"id":299568062,"identity":"8a4c06d6-b922-48bc-a851-b813e5c3b1d1","order_by":1,"name":"Syed Amir Gilani","email":"","orcid":"","institution":"Green International University","correspondingAuthor":false,"prefix":"","firstName":"Syed","middleName":"Amir","lastName":"Gilani","suffix":""},{"id":299568063,"identity":"a7b64c48-90f7-4530-a40d-377e52cec6d7","order_by":2,"name":"Asif Hanif","email":"","orcid":"","institution":"The University of Lahore","correspondingAuthor":false,"prefix":"","firstName":"Asif","middleName":"","lastName":"Hanif","suffix":""},{"id":299568064,"identity":"c72d51bb-3ada-4a10-8d83-b215646e9076","order_by":3,"name":"Raham Bacha","email":"","orcid":"","institution":"The University of Lahore","correspondingAuthor":false,"prefix":"","firstName":"Raham","middleName":"","lastName":"Bacha","suffix":""},{"id":299568065,"identity":"b785c816-6c53-4bab-be6b-977bf5d16c0b","order_by":4,"name":"Zareen Fatima","email":"","orcid":"","institution":"The University of Lahore","correspondingAuthor":false,"prefix":"","firstName":"Zareen","middleName":"","lastName":"Fatima","suffix":""}],"badges":[],"createdAt":"2024-05-01 08:25:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4353185/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4353185/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":56197027,"identity":"1710d397-7f69-479e-a81c-8251b525cd9a","added_by":"auto","created_at":"2024-05-09 18:20:25","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":31600,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4353185/v1/9e392657f1ef9a14b1b30e34.jpg"},{"id":56198604,"identity":"e5a3aa95-812d-4547-b7b6-e1663dce97c6","added_by":"auto","created_at":"2024-05-09 18:36:27","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":48595,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4353185/v1/bf9e0d32f63a695d3a414f68.jpg"},{"id":56197031,"identity":"aaf27507-5214-4ada-a348-8705361f64d4","added_by":"auto","created_at":"2024-05-09 18:20:28","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":66819,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4353185/v1/d3dbd3ed8ef066a246b01c88.jpg"},{"id":56197028,"identity":"600addea-48fe-4f97-8e42-8c6efd06b083","added_by":"auto","created_at":"2024-05-09 18:20:27","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":73495,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4353185/v1/8381280dc44170e3dcce8b99.jpg"},{"id":56198148,"identity":"e33200ed-33f3-4248-9164-87370e3ef9f8","added_by":"auto","created_at":"2024-05-09 18:28:27","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":65652,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Fig5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4353185/v1/e85cb02d5df4b3b04fb0cf60.jpg"}],"financialInterests":"No competing interests reported.","formattedTitle":"Provocative measures in the sonographic evaluation of varicocele in obese patients and relation of different grades of varicocele with intra-testicular hemodynamics","fulltext":[{"header":"Introduction","content":"\u003cp\u003eVaricoceles is the dilation and tortuosity of testicular drainage in the epididymis and pampiniform plexus in the spermatic cord.\u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/sup\u003e As blood stays for long time in the veins causing territorial increase in the temperature.\u003csup\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/sup\u003e Sperms cells are very sensitive to a minimal increase in temperature, therefore, dead sperm cells increases in the semen sample instead of active and motile ones needed for fertilization.\u003csup\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/sup\u003e Secondly engorgement of the testicular venous system can lead to increase in blood flow resistance.\u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e These dilated and tortuous veins in pampiniform plexus of gonadal veins above the testicle, are the leading correctible cause of male-factor infertility.\u003csup\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/sup\u003e It is found in 30\u0026ndash;40% of men with primary infertility and 51\u0026ndash;77% of men with secondary infertility.\u003csup\u003e(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e Varicoceles reduce sperm quantity and quality, it can also effects testicular development in adolescents, cause pain and can decrease testosterone levels.\u003csup\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePhysical examination is the standard diagnostic method for varicocele, but usually difficult to estimate the existence of varicocele by use of physical examination alone. Mild varicoceles are impalpable and asymptomatic and are diagnosed only with ultrasound evaluation owing to thick scrotal skin and a strong cremasteric reflex.\u003csup\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/sup\u003e Doppler Ultrasonography is a non-invasive imaging technique and is highly sensitive in detecting blood flow abnormalities, including retrograde blood flow characteristic of varicoceles and aiding in the diagnosis and grading of varicoceles.\u003csup\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/sup\u003e While scrotal ultrasonography is the gold standard for diagnosing varicoceles, but it may not always provide conclusive results.\u003csup\u003e(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/sup\u003e Factors such as operator\u0026rsquo;s experience, technique, equipment quality, and patient anatomy especially obesity can affect the accuracy of sonographic imaging.\u003csup\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/sup\u003e During Doppler sonography severe and moderate varicoceles are easy to identify, but mild varicoceles are difficult to diagnose specially in obese patients.\u003csup\u003e(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e Therefore, the role of scrotal Doppler sonography with provocative measures like Valsalva maneuver and standing position is essential for the interpretation of an indecisive scrotal examination.\u003csup\u003e(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn the standing positions the blood is pulled towards the center of gravity by the gravitational force. However more force is required for it to return to the heart and in most of the cases the blood is pooled in the peripheral veins.\u003csup\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/sup\u003e The persistence blood pooling in the peripheral veins leading to varicocele in the standing position but spontaneously subsides in the lying position. In usual, the testicular sonography is performed in supine laying position wherein the minimal varicocele subsides, and the sonographic findings yield false negative results.\u003csup\u003e(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/sup\u003e Similarly, during Valsalva maneuver the abdominal IVC is compressed, and the blood return is ceased leading to the peripheral blood pooling. However, with the used of this maneuver the minimal varicosity will be reliably evaluated, but more cooperation is needed from the patient which is practically impossible in most of the patients.\u003csup\u003e(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/sup\u003e In general, sonography of every structure but particularly the diagnosis of varicocele is a challenging task in obese individuals. In obese individuals the veins are compressed by the excessive bulk of subcutaneous fats and minimal varicocele is missed. Secondly the excessive accumulation of subcutaneous fats are difficult to be penetrated by the ultrasound to image the deep varicocele.\u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eGrayscale ultrasound along with Doppler capability is not only important for the identifications and measurements of the testicular venous drainage but it is also used to measure the hemodynamic parameters like peak systolic velocity, end-diastolic velocity, Resistive index, pulsatility index and other detailed characteristics.\u003csup\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/sup\u003e It was there for intended in the current study to evaluate the impact of Valsalva maneuver and standing position in the detection of varicoceles using color Doppler sonography. Additionally, it is aimed, if the provocative measures standing position and Valsalva were proved to affect the varicocele and hemodynamic changes in the testicular arteries then these parameters will be incorporated in the current sonographic criteria of varicoceles, specifically focusing on obese patients. If the varicocele is diagnosed timely then the varicocele related male infertility could properly be managed.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003e This cross-sectional study was conducted at Gilani Ultrasound Center, Lahore, Pakistan from March 2020 to October 2023 while including 107 infertile obese patients after approval of Institutional Research Ethical Committee, the University of Lahore. However, those with any clinical evidence of infertility in their spouses or with previous history of testicular trauma or surgery, Patients with anomalous genitalia, lower limb edema, abdominal ascites or pleural effusion were excluded from the study.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSonographic Technique:\u003c/h2\u003e \u003cp\u003eToshiba Xario equipped with the linear transducer having frequency range 7\u0026ndash;14 MHZ was used. Gray scale, color, power, and pulsed Doppler were used for the scanning of patients. American Institute of Ultrasound in Medicine (AIUM) guidelines for the scrotal ultrasound were followed.\u003csup\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/sup\u003e Patients were positioned supine and instructed to undress from the waist down, lying on an examination table for the assessment. A towel or sheet was used to cover the patient's body for privacy. The scrotum was placed on an appropriate support and distended. The latter was accomplished by having the patient exert moderate upward traction on the penis (toward the umbilicus). A water-based gel was applied to the scrotal area and the transducer was moved gently over the scrotal area. Special attention was given to pampiniform plexus, and the vein diameter was measured on gray scale on both sides. Color Doppler Ultrasound assessments were made under basal (resting) conditions then during the Valsalva maneuver. Then the patient was advised to stand and the evaluation was repeated with the same Valsalva maneuver. Color Doppler parameters were optimized for the evaluation of slow flow. \u003csup\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/sup\u003e Lower scale of about 3cm/s was selected with wall filter at minimum levels, gain at the maximum level permitted by the presence of artifacts, elective focus on the region of interest) and standardized. The blood flow direction with Valsalva and normal respiration was observed on the grayscale and color Doppler to observe the reflux of blood. The findings of vein diameter more than 2.5 mm and blood flow reflux were considered to be suggestive of varicocele.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis:\u003c/h2\u003e \u003cp\u003eStatistical Package for the Social Sciences (SPSS) version 24 (SPSS 24, IBM, Armonk, NY, United States of America) was used for the analysis of data. Mean and standard deviation of the demographic parameters of the sample were documented. Comparison of the means of the age, BMI, right sided varicose veins diameter in laying position, right sided varicose veins diameter in standing position, left sided varicose veins diameter in laying position, left sided varicose veins diameter in standing position, right sided intratesticular artery resistive index and pulsatility index, left sided intratesticular artery resistive index and pulsatility index, right sided testicular volume and left sided testicular volume in various grades of varicocele were documented. The statistical significance of the means in various grades of varicocele were calculated with the help of one way ANOVA.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTotal 107 patients were included in this study with mean age of 30.16\u0026thinsp;\u0026plusmn;\u0026thinsp;3.62 (23 to 39) years. The mean of BMI was 34.51\u0026thinsp;\u0026plusmn;\u0026thinsp;2.09 (30 to 40), the mean of right sided varicose veins diameter in laying position was 2.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75 (0.8 to 5.1)mm, while the mean of right sided varicose veins diameter in standing position was 2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86 (1.1 to 6.0)mm, and the mean of left sided varicose veins diameter in laying position was 2.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68 (0.9 to 5.5)mm, while the mean of left sided varicose veins diameter in standing position was 3.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75 (1.3 to 6.4)mm. The mean of right sided intratesticular artery resistive index was 0.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07 (0.49 to 0.88), while the mean of left sided intratesticular artery resistive index was 0.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07 (0.50 to 0.92). The mean of right sided intratesticular artery pulsatility index was 1.52\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46 (0.88 to 3.11), while the mean of left sided intratesticular artery pulsatility index was 1.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44 (0.82 to 3.20). The mean of right testicular volume was 16.07\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2 (12 to 23.1) cc, and the mean of left testicular volume was 12.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9 (12 to 23.4)cc. The testicular parenchyma of 4 (3.7 %) was hypoechoic, while it was hyperechoic in 103 (96.3 %).\u003c/p\u003e \u003cp\u003eBilateral varicocele were observed in 35 (32.7 %), riht sided varicocele were seen in 6 (5.6 %).and leftsided varicocele were seen in 66 (61.7%). Grade 1 varicocele was seen in 53 (49.53%), Grade 2 in 43 (40.19%) and grade 3 in 11 (10.28%) individuals as shown in the graph (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eIn most of the individuals the BMI was ranging from 32 to 36 as you can see BMI 32 in 13 (12.1%) 33 in 17 (15.9%), 34 in 19 (17.8%), 35 in 17 (15.9%) and 36 in 23 (21.5%), but above and below this range there were only single or 2 individuals were observed maximum 40 BMI. Comparison of the means of the age, BMI, right sided varicose veins diameter in laying position, right sided varicose veins diameter in standing position, left sided varicose veins diameter in laying position, left sided varicose veins diameter in standing position, right sided intratesticular artery resistive index, left sided intratesticular artery resistive index. Right sided testicular volume and left sided testicular volume in various grades of varicocele are shown in the adjacent table. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean with standard deviation and p-value of the Rt Intratesticular PI, Lt Intratesticular PI, Rt Intratesticular RI, Lt Intratesticular RI, Rt Varicose veins diameter in lying position, Rt Varicose veins diameter in standing position, Lt Varicose veins diameter in lying position, Lt Varicose veins diameter in standing position, Rt Testicular Volume, Lt Testicular Volume in various grades of varicocele.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eMean with standard deviation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade-I (N\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGrade-II (N\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGrade-III (N\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRt Intratesticular PI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.27\u0026thinsp;\u0026plusmn;\u0026thinsp;0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e2.58\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLt Intratesticular PI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e2.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRt Intratesticular RI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.79\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLt Intratesticular RI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRt Varicose veins diameter in lying position\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.98\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRt Varicose veins diameter in standing position\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e4.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLt Varicose veins diameter in lying position\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e4.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLt Varicose veins diameter in standing position\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e4.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRt Testicular Volume\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e16.89\u0026thinsp;\u0026plusmn;\u0026thinsp;1.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.70\u0026thinsp;\u0026plusmn;\u0026thinsp;2.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e13.63\u0026thinsp;\u0026plusmn;\u0026thinsp;1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLt Testicular Volume\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e16.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e14.25\u0026thinsp;\u0026plusmn;\u0026thinsp;2.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e34.13\u0026thinsp;\u0026plusmn;\u0026thinsp;1.665\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e34.64\u0026thinsp;\u0026plusmn;\u0026thinsp;2.431\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e36.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOne way ANOVA test was applied to know the relationship of age, BMI, right sided varicose veins diameter in laying position, right sided varicose veins diameter in standing position, left sided varicose veins diameter in laying position, left sided varicose veins diameter in standing position, right sided intratesticular artery resistive index, left sided intratesticular artery resistive index. Right sided testicular volume and left sided testicular volume with various grades of varicocele. Statistically there was no relationship between patient age and grades of varicocele with p-value of 0.67. Statistically significant relation was seen in BMI with grades of varicocele having a p-value of 0.03. Amongst grades of varicocele and right sided varicose veins diameter in laying position, right sided varicose veins diameter in standing position, left sided varicose veins diameter in laying position, left sided varicose veins diameter in standing position, right sided intratesticular artery resistive index, left sided intratesticular artery resistive index. Right sided testicular volume and left sided testicular volume with various grades of varicocele, statistically very strong relationship is observed with p-value less than 0.05 for each.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe 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\u0026thinsp;\u0026plusmn;\u0026thinsp;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\u003csup\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/sup\u003e as shown in (Fig.\u0026nbsp;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.\u003csup\u003e(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/sup\u003e 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.\u003csup\u003e(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eLeft 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.\u003csup\u003e(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/sup\u003e 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.\u003csup\u003e(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn 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\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75 (0.8 to 5.1)mm, while the mean of right sided varicose veins diameter in standing position was 2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86 (1.1 to 6.0)mm, and the mean of left sided varicose veins diameter in laying position was 2.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68 (0.9 to 5.5)mm, while the mean of left sided varicose veins diameter in standing position was 3.11\u0026thinsp;\u0026plusmn;\u0026thinsp;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.\u003csup\u003e(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/sup\u003e 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.\u003csup\u003e(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/sup\u003e 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.\u003csup\u003e(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn 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.\u003csup\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTesticular 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.\u0026nbsp;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.\u0026nbsp;4). While In grade III varicocele the mean PI of the left intratesticular artery was 2.63 as shown in (Fig.\u0026nbsp;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.\u003csup\u003e(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSignificant impact of the provocative measures like standing position and Valsalva maneuver is observe on the sonographic diagnosis of varicocele and statically significant increases in the intratesticular artery resistive and pulsatility indices was noted.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003e1- Zain ul Hasan (Corresponding author) MAIN AUTHOR2- Syed Amir Gilani (Co- author)3- Asif Hanif (Analyses)4- Raham Bacha (Data collection)5- Zareen Fatima (Proof reading)\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eda Silva HVN, Meller RL, Ogundipe EA, Rochon PJ, editors. Varicoceles: overview of treatment from a radiologic and surgical perspective. Seminars in Interventional Radiology; 2022: Thieme Medical Publishers, Inc.\u003c/li\u003e\n\u003cli\u003eComby P-O, Guillen K, Chevallier O, Lenfant M, Pellegrinelli J, Falvo N, et al. Endovascular use of cyanoacrylate-lipiodol mixture for peripheral embolization: Properties, techniques, pitfalls, and applications. Journal of Clinical Medicine. 2021;10(19):4320.\u003c/li\u003e\n\u003cli\u003eAl-Nawab NAA, Ali IH, Al-Khafaji LKJ. The special techniques for Semen analysis and preparation. Research Journal of Pharmacy and Technology. 2021;14(9):4941-6.\u003c/li\u003e\n\u003cli\u003eShahat A, Rizzoto G, Kastelic J. Amelioration of heat stress-induced damage to testes and sperm quality. Theriogenology. 2020;158:84-96.\u003c/li\u003e\n\u003cli\u003eGalea M, Brincat MR, Calleja-Agius J. A review of the pathophysiology and evidence-based management of varicoceles and pelvic congestion syndrome. Human Fertility. 2023;26(6):1597-608.\u003c/li\u003e\n\u003cli\u003eLotti F, Zitzmann M, Behre HM. Ultrasound Imaging in Andrology. Andrology: Male Reproductive Health and Dysfunction: Springer; 2023. p. 93-131.\u003c/li\u003e\n\u003cli\u003eBai S, Li Y, Hu M-H, Wu L, Shui L-J, Wang X-H, et al. Association of sexually transmitted infection with semen quality in men from couples with primary and secondary infertility. Asian Journal of andrology. 2022;24(3):317-22.\u003c/li\u003e\n\u003cli\u003eAgarwal A, Baskaran S, Parekh N, Cho C-L, Henkel R, Vij S, et al. Male infertility. The Lancet. 2021;397(10271):319-33.\u003c/li\u003e\n\u003cli\u003eKang C, Punjani N, Lee RK, Li PS, Goldstein M, editors. Effect of varicoceles on spermatogenesis. Seminars in Cell \u0026amp; Developmental Biology; 2022: Elsevier.\u003c/li\u003e\n\u003cli\u003ePozza C, Tenuta M, Sesti F, Bertolotto M, Huang DY, Sidhu PS, et al. Multiparametric Ultrasound for Diagnosing Testicular Lesions: Everything You Need to Know in Daily Clinical Practice. Cancers. 2023;15(22):5332.\u003c/li\u003e\n\u003cli\u003eullah Rabbani H, Fahim S, Jan MA, Bacha R, Saddique Z. ASSOCIATION OF SONOGRAPHIC GRADES OF VARICOCELE WITH SEMEN ANALYSIS IN INFERTILE MEN IN KHYBER PAKHTUNKHWA. Journal of Population Therapeutics and Clinical Pharmacology. 2023;30(18):1477-83.\u003c/li\u003e\n\u003cli\u003eLehner K, Ingram C, Bansal U, Baca C, Balasubramanian A, Thirumavalavan N, et al. Color Doppler ultrasound imaging in varicoceles: Is the difference in venous diameter encountered during Valsalva predictive of palpable varicocele grade? Asian Journal of Urology. 2023;10(1):27-32.\u003c/li\u003e\n\u003cli\u003eSpada S, Arlt S, De Felice D, England GC, Russo M. Digital postprocessing analysis of prostatic perfusion in neutered dogs. Veterinary Radiology \u0026amp; Ultrasound. 2024.\u003c/li\u003e\n\u003cli\u003eMansour HAE-h. Infertility diagnosis and management. Beni-Suef University Journal of Basic and Applied Sciences. 2023;12(1):81.\u003c/li\u003e\n\u003cli\u003eKasman AM, Del Giudice F, Eisenberg ML. Section 2 The Biology of Male Reproduction and Infertility Chapter 11. Men\u0026apos;s Reproductive and Sexual Health Throughout the Lifespan: An Integrated Approach to Fertility, Sexual Function, and Vitality. 2023:87.\u003c/li\u003e\n\u003cli\u003eGhorbani H, Ghorbani M, Rahmanipour E, Rafeemanesh E, Ghodsi A, Jarahi L, et al. Relationship between occupational and physical activity with varicocele. 2023.\u003c/li\u003e\n\u003cli\u003eDohare S, Yadav K, Puranik M, Dave PK. A COMPARATIVE STUDY FOR CLINICAL ASSESSMENT \u0026amp; DIAGNOSTIC ACCURACY OF ULTRASOUND IMAGING IN SCROTAL AND INGUINAL PATHOLOGIES. Int J Acad Med Pharm. 2024;6(1):1477-84.\u003c/li\u003e\n\u003cli\u003eCokkinos DD, Partovi S, Rafailidis V, Sierrou C, Fragkouli T, Tsolaki S, et al. Role and added value of contrast enhanced ultrasound of the painful scrotum in the emergency setting. Journal of Ultrasound. 2023;26(2):563-75.\u003c/li\u003e\n\u003cli\u003eManzoor I, Gilani SA, Bacha R, Fatima M. Association of spectral Doppler cardiac activity in the lower limb veins and echocardiographic findings in patients with tricuspid regurgitation. Journal of Ultrasonography. 2020;20(81):111-5.\u003c/li\u003e\n\u003cli\u003eKim YS, Kim SK, Cho I-C, Min SK. Efficacy of scrotal Doppler ultrasonography with the Valsalva maneuver, standing position, and resting-Valsalva ratio for varicocele diagnosis. Korean journal of urology. 2015;56(2):144.\u003c/li\u003e\n\u003cli\u003eAlcantara-Zapata D, Nazzal C, Mu\u0026ntilde;oz S, De Gregorio N, Marchetti N, Behn C. Varicocele at High Altitude; Venous Outflow Restriction by Hypobaric Hypoxia. Current Vascular Pharmacology. 2022;20(3):303-9.\u003c/li\u003e\n\u003cli\u003ePunjani N, Wald G, Al-Hussein Alawamlh O, Dudley V, Goldstein M. Standing ultrasound adds clinical utility for the diagnosis of varicoceles. The Journal of Urology. 2021;206(4):1001-8.\u003c/li\u003e\n\u003cli\u003eNieschlag E, Kliesch S, Behre HM. Varicocele. Andrology: Male Reproductive Health and Dysfunction: Springer; 2023. p. 257-64.\u003c/li\u003e\n\u003cli\u003eWang K, Gao Y, Wang C, Liang M, Liao Y, Hu K. Role of oxidative stress in varicocele. Frontiers in Genetics. 2022;13:850114.\u003c/li\u003e\n\u003cli\u003eItani M, Kipper B, Corwin MT, Burgan CM, Fetzer DT, Shenoy-Bhangle AS, et al. Right-sided scrotal varicocele and its association with malignancy: a multi-institutional study. Abdominal Radiology. 2021;46:2140-5.\u003c/li\u003e\n\u003cli\u003eArshad MA, Siddiqui AA, Rehman KU. Subinguinal versus peritesticular diameters of varicocele veins in the supine and standing posture. J Pak Med Assoc. 2021;71:2766-9.\u003c/li\u003e\n\u003cli\u003eNajari BB, Katz MJ, Schulster ML, Lee DJ, Li PS, Goldstein M. Increased body mass index in men with varicocele is associated with larger spermatic vein diameters when supine. Urology. 2016;89:40-4.\u003c/li\u003e\n\u003cli\u003e王世鋒, 蔣以仁, 羅華安, 陳國強, 謝德生, 林志明. Intratesticular Arterial Pulsatility and Resistance Index in Males with Scrotal Varicocele. 輔仁醫學期刊. 2016;14(1):1-7.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":false,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Obesity, Valsalva maneuver, Male infertility, Varicocele","lastPublishedDoi":"10.21203/rs.3.rs-4353185/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4353185/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDoppler 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.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo 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.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis 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\u0026ndash;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.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mean age of 30.16\u0026thinsp;\u0026plusmn;\u0026thinsp;3.62 (23 to 39) years. The mean of BMI was 34.51\u0026thinsp;\u0026plusmn;\u0026thinsp;2.09 (30 to 40), the mean of right-sided varicose veins diameter in laying position was 2.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75 (0.8 to 5.1)mm, while the mean of right-sided varicose veins diameter in standing position was 2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86 (1.1 to 6.0)mm, and the mean of left-sided varicose veins diameter in laying position was 2.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68 (0.9 to 5.5)mm, while the mean of left-sided varicose veins diameter in standing position was 3.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75 (1.3 to 6.4)mm. The mean of right-sided intratesticular artery resistive index was 0.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07 (0.49 to 0.88), while the mean of left-sided intratesticular artery resistive index was 0.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07 (0.50 to 0.92).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eA 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.\u003c/p\u003e","manuscriptTitle":"Provocative measures in the sonographic evaluation of varicocele in obese patients and relation of different grades of varicocele with intra-testicular hemodynamics","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-09 18:20:09","doi":"10.21203/rs.3.rs-4353185/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a57f1e75-a6ea-4c38-93b8-faec70287dd0","owner":[],"postedDate":"May 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-09T18:28:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-09 18:20:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4353185","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4353185","identity":"rs-4353185","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}