Reference Standard Examination Research Articles

Remote physical examination for temporomandibular disorders.

There is a need to further develop telemedicine approaches because of the immediate and perhaps long-term consequences of the coronavirus disease 2019. Thus, a remote protocol for assessment of patients with temporomandibular disorders (TMD) was developed, and the agreement of this protocol was compared with the guidelines of the Diagnostic Criteria for TMD (DC/TMD). A total of 16 individuals were first assessed by a reference standard examination (RSE) and 3 other examinations applied in a random order by 3 examiners: standard physical examination (standard examination), physical examination keeping 2-m distance (physical distanced examination), and examination conducted with the aid of video communication technology (video communication examination). The primary outcomes were the diagnoses of myalgia of the masseter and temporalis muscles and arthralgia. The diagnoses of intra-articular joint disorders were considered secondary outcomes because of a less impact on psychosocial functioning and quality of life when compared with the pain-related diagnoses. The Fleiss kappa coefficient and its 95% confidence interval were computed to determine the level of agreement in diagnoses between each examination protocol and the RSE. There was substantial to almost perfect agreement between the RSE and all the examination protocols for the diagnoses of myalgia (0.86-1.00) and arthralgia (0.74-0.87) (P < 0.001). On the other hand, there was an overall poor agreement (0.30-0.58) between the RSE and all the protocols for the diagnosis of disk displacement with reduction. Remote assessment of patients with pain-related TMD is feasible and presents a high degree of accuracy.

One-Size-Fits-All Approach Does Not Work for Gynecology Trainees Learning Endometriosis Ultrasound Skills.

To evaluate whether gynecologic surgical trainees (fellows) can become competent in the real-time classification of the pouch of Douglas (POD) obliteration state and direct visualization of bowel deep endometriosis (DE) during a program with a prespecified number of transvaginal ultrasound (TVUS) examinations. We performed a prospective study between December 2017 and December 2018. Three fellows (F1-F3) performed 50 scans each, which were all supervised by an expert sonologist, who performed the reference standard TVUS examination. The fellows performed a focused TVUS examination to assess the bowel and POD state, having been blinded to the patient's clinical history and reference standard findings. Immediate feedback and hands-on teaching were provided after each of the fellow's official classifications. To evaluate the number of scans needed to gain competency, the cumulative summation test for the learning curve was used. A total of 150 examinations were performed on 145 patients. Twenty-six (17.9%) patients had a diagnosis of bowel DE, and 34 (23.4%) were classified as having a negative sliding sign by the reference standard. The overall accuracy of the presence/absence of bowel DE was 90% (range, 82%-94%). The overall accuracy of POD state classification was 93% (range, 90%-96%). The cumulative summation test for the learning curve for bowel DE showed that F1 did not reach competency by 50 scans, whereas F2 and F3 required 21 and 25 scans, respectively. For POD obliteration, F2 did not reach competency, whereas F1 and F3 required 40 and 22 scans. Not all trainees can reach competency for TVUS evaluations of POD obliteration and bowel DE in a predefined number of scans.

Standards de qualité pour la pratique de l’examen écho-Doppler dans l’étude des malformations et tumeurs vasculaires. Rapport de la Société française de médecine vasculaire (SFMV) : actualisation 2018

To describe an optimal method of examination in relation to the clinical question and hypothesis. To homogenize practice, methods, glossary, and reporting. To provide good practice reference points, and promote a quality process. The 3 levels of examination; their clinical indications and goals. The reference standard examination (level 2), its variants according to clinical needs. The minimal content of the examination report; the letter to the referring physician (synthesis, conclusion and proposal for further investigation and/or therapeutic management). Commented glossary (anatomy, hemodynamics, semiology). Technical bases. Setting and use of ultrasound devices. Here, we discuss ultrasonography methods of using of ultrasonography for the assessment of peripheral vascular malformations and tumors (limbs, face, trunk).

Quality standards for duplex ultrasonographic assessment (duplex us) of abdominal aortic stent grafts

To describe an optimal level of examination adjusted to the indication or clinical hypothesis; to establish harmonious practices, methodologies, terminologies, results description and report; to provide good practice reference points and to promote a high quality process. The three levels of examination, indications and objectives for each level; the reference standard examination (level 2) and its variants according to indications; the minimal content of the exam report, the medical conclusion letter to the corresponding physician (synthesis, conclusion and management suggestions); commented glossary (anatomy, hemodynamics, signs and symptoms); technical basis; device settings. Here, we discuss duplex ultrasound for the supervision of the aortic stent grafts.

Anterior Segment Imaging for Anterior Chamber Angle Assessment

Objective: To review and update the available methods for evaluating the anterior chamber angle (ACA). Methods: We analyzed and discussed the main findings of selected published articles on ACA assessment and performed a critical review of each method. Results: Gonioscopy is the reference standard examination for evaluation of ACA. Because no other examination technique permits appropriate differentiation between apposition and synechial angle closure, indentation gonioscopy is essential to determine proper clinical management decisions. Imaging techniques such as ultrasound biomicroscopy and anterior segment-optical coherence tomography are useful and promising modalities for ACA assessment; however, ophthalmologists need to look for good-quality images and understand the particularities and inherent limitations of these techniques for proper interpretation of the results. Conclusion: Imaging technologies may represent an important adjunct for the clinical assessment of ACA; however, longitudinal studies should be performed to determine the relative values of their findings in the management of patients with angle closure. Until then, none of these imaging techniques can replace gonioscopy as the reference standard examination.

Diagnostic Accuracy of Technologies for Glaucoma Case-Finding in a Community Setting

To assess case-finding performance of the Frequency Doubling Technology Perimeter (FDT) (CarlZeiss Meditec, Inc., Dublin, CA), Moorfields Motion Displacement Test (MMDT) (Moorfields Eye Hospital, London, UK), iVue optical coherence tomography (OCT) (Optovue Inc., Fremont, CA), and ocular response analyzer (ORA) (Reichert Ophthalmic Instruments, Depew, NY), alone or combined, for primary open-angle glaucoma (POAG). Cross-sectional, observational, community-based study. A total of 505 subjects aged ≥60 years recruited from a community setting using no predefined exclusion criteria. Subjects underwent 4 index tests conducted by a technician unaware of subjects' ocular status. FDT and MMDT were used in suprathreshold mode. iVue OCT measured ganglion cell complex and retinal nerve fiber layer (RNFL) thickness. Reference standard was full ophthalmic examination by an experienced clinician who was masked to index test results. Subjects were classified as POAG (open drainage angle, glaucomatous optic neuropathy, and glaucomatous field defect), glaucoma suspect, ocular hypertension, or non-POAG/nonocular hypertension. Test performance evaluated the individual as the unit of analysis. Diagnostic accuracy was assessed using predefined cutoffs for abnormality, generating sensitivity, specificity, and likelihood ratios. Continuous data were used to derive estimates of sensitivity at 90% specificity and partial area under the receiver operating characteristic curve (AUROC) plots from 90% to 100% specificity. From the reference standard examination, 26 subjects (5.1%) had POAG and 32 subjects (6.4%) were glaucoma suspects. Sensitivity (95% confidence interval) at 90% specificity for detection of glaucoma suspect/POAG combined was 41% (28-55) for FDT, 35% (21-48) for MMDT, and 57% (44-70) for best-performing OCT parameter (inferior quadrant RNFL thickness); for POAG, sensitivity was 62% (39-84) for FDT, 58% (37-78) for MMDT, and 83% (68-98) for inferior quadrant RNFL thickness. Partial AUROC was significantly greater for inferior RNFL thickness than visual-function tests (P < 0.001). Post-test probability of glaucoma suspect/POAG combined and definite POAG increased substantially when best-performing criteria were combined for FDT or MMDT, iVue OCT, and ORA. Diagnostic performance of individual tests gave acceptable accuracy for POAG detection. Low specificity of visual-function tests precludes their use in isolation, but case detection improves by combining RNFL thickness analysis with visual function tests.

Performance of advanced technologies for community‐based glaucoma case‐finding

AbstractPurpose To identify if the Frequency Doubling Technology perimeter (FDT), Moorfields Motion Displacement Test (MDT), iVue Optical Coherence Tomographer (OCT) and Ocular Response Analyser (ORA), alone or in combination, improve case detection of primary open angle glaucoma (POAG) in a population aged over 59 years.Methods 505 volunteers aged 60 to 92 years (median age 68) completed all 4 screening tests conducted without knowledge of subjects’ ocular status. FDT and MDT were used in suprathreshold mode. iVue OCT measured ganglion cell complex and retinal nerve fibre layer thickness. Each subject then received a full ophthalmic examination by an experienced clinician, masked to preceding test results. Based on this evaluation, subjects were classified as normal, glaucoma suspects or POAG (defined as an open drainage angle, glaucomatous optic neuropathy, and glaucomatous field defects).Results Based on the reference standard examination, 26 (5.1%) subjects were classified as POAG, and 32 (6.4%) suspect glaucoma. Sensitivity at 90% specificity for detection of POAG was 63% (95% CI: 39 to 82) for FDT, 54% (33 to 74) for MDT, and 82% (64 to 95) for best performing OCT parameter (inferior RNFL thickness). Using these criteria, partial AUROC was significantly greater for inferior RNFL thickness than other tests (p=&lt;0.01).The probability of having POAG increased substantially when best‐performing criteria were combined for perimetry, iVue OCT and ORA.Conclusion Diagnostic performance of individual tests gave acceptable accuracy for POAG detection in a representative sample of elderly subjects. For case‐finding, our study supports combining retinal nerve fibre layer thickness analysis with performance on vision‐function tests.

Standards de qualité pour la pratique de l’examen écho-doppler dans l’étude des malformations et tumeurs vasculaires. Rapport de la Société française de médecine vasculaire (SFMV)

THE QUALITY STANDARDS OF THE FRENCH SOCIETY OF VASCULAR MEDICINE FOR THE ULTRASONOGRAPHIC ASSESSMENT OF VASCULAR MALFORMATIONS ARE BASED ON THE TWO FOLLOWING REQUIREMENTS: Technical know-how: mastering the use of ultrasound devices and the method of examination. Medical know-how: ability to adapt the methods and scope of the examination to its clinical indication and purpose, and to rationally analyze and interpret its results. AIMS OF THE QUALITY STANDARDS: To describe an optimal method of examination in relation to the clinical question and hypothesis. To achieve consistent practice, methods, glossary, and reporting. To provide good practice reference points, and promote a high-quality process. ITEMS OF THE QUALITY STANDARDS: The three levels of examination; their clinical indications and goals. The reference standard examination (level 2), its variants according to clinical needs. The minimal content of the examination report; the letter to the referring physician (synthesis, conclusion and proposal for further investigation and/or therapeutic management). Commented glossary (anatomy, hemodynamics, semiology). Technical bases. Settings and use of ultrasound devices. Here, we discuss the methods of using ultrasonography for the assessment of peripheral vascular malformations and tumors.

Standards de qualité pour la pratique des examens Doppler et écho-Doppler artériel des membres inférieurs en médecine vasculaire. Rapport de la Société française de médecine vasculaire (SFMV)

The quality standards of the French Society of Vascular Medicine for the ultrasound assessment of lower limb arteries in vascular medicine practice are based on the principle that these examinations have to meet two requirements: technical know-how (knowledge of devices and methodologies); medical know-how (level of examination matching the indication and purpose of the examination, interpretation and critical analysis of results). OBJECTIVES OF THE QUALITY STANDARDS: To describe an optimal level of examination adjusted to the indication or clinical hypothesis; to homogenize practices, methodologies, terminologies, results description and report; to provide good practice reference points and to promote a high quality process. THEMES OF THE QUALITY STANDARDS: The three levels of examination, indications and objectives for each level; the reference standard examination (level 2) and its variants according to indications; the minimal content of the exam report, the medical conclusion letter to the corresponding physician (synthesis, conclusion and management suggestions); commented glossary (anatomy, hemodynamics, signs and symptoms); technical basis. Device settings. Here, we discuss CW-Doppler and Duplex ultrasound in various indications for lower limbs arteries assessment.

Sonographic Detection of Pneumothorax by Radiology Residents as Part of Extended Focused Assessment With Sonography for Trauma

The purpose of this study was to assess the accuracy of sonographic pneumothorax detection by radiology residents as a part of extended focused assessment with sonography for trauma (eFAST). In a prospective study, a sonographic search for pneumothoraces was performed as part of a standard FAST examination by the on-call resident. Each lung field was scanned at the second to fourth anterior intercostal spaces and the sixth to eighth midaxillary line intercostal spaces. A normal pleural interface was identified by the presence of parietal-over-visceral pleural sliding with "comet tail" artifacts behind. Absence of these normal features indicated a pneumothorax. The sonographic diagnosis was correlated with supine chest radiography and chest computed tomography (CT). A total of 338 lung fields in 169 patients were included in the study. Patients underwent eFAST, chest radiography, and chest CT when clinically indicated. Chest CT was considered the reference standard examination. Computed tomography identified 43 pneumothoraces (13%): 34 small and 9 moderate. On chest radiography, 7 pneumothoraces (16%) were identified. Extended FAST identified 23 pneumothoraces (53%). Compared with CT, eFAST had sensitivity of 47%, specificity of 99%, a positive predictive value of 87%, and a negative predictive value of 93%. All of the moderate pneumothoraces were identified by eFAST. Twenty small pneumothoraces missed by eFAST did not require drainage during the hospitalization period. Extended FAST performed by residents is an accurate and efficient tool for early detection of clinically important pneumothoraces.

Clinical Significance of Intramuscular Cysts in the Rotator Cuff and Their Relationship to Full- and Partial-Thickness Rotator Cuff Tears

Secondary signs have been sought to help in the MR diagnosis of rotator cuff tears, especially partial-thickness tears. We sought to determine whether intramuscular cysts are always present with rotator cuff tears and the types of rotator cuff tears with which they present, and to establish the clinical significance of finding intramuscular cysts. Retrospective analysis of our institution's database of 5,101 MRI examinations of the shoulder during an 8-year period resulted in 187 examinations in 185 patients who were thought to have intramuscular cysts. Of the 187 examinations, 134 shoulders in 132 patients (62 women, 70 men) met our criteria for an intramuscular cyst. Of the 134 shoulders with intramuscular cysts, 102 (76.1%) showed imaging findings of both intramuscular cysts and rotator cuff tears. Thirty-two of the 134 (23.9%) shoulders were diagnosed with only an intramuscular cyst and were not associated with a rotator cuff tear. Fifty-five of 102 (53.9%) shoulders consisted of an intramuscular cyst associated with a full-thickness rotator cuff tear, and 47 of 102 (46.1%) shoulders presented with a partial-thickness rotator cuff tear. Forty-eight of 102 (47.1%) shoulders with both an intramuscular cyst and a rotator cuff tear also underwent the reference standard arthroscopy examination to confirm the MRI findings. In 46 of 48 (95.8%) shoulders that underwent arthroscopy, the findings confirmed the imaging evidence; the other two cases were shown to have an intact rotator cuff at arthroscopy. Our study echoes the findings of previous studies that suggest a relationship between intramuscular cysts and full- and partial-thickness rotator cuff tears but illustrates that the incidence of an isolated intramuscular cyst is higher than previously expected. When intramuscular cysts present with rotator cuff tears, they present with full- and partial-thickness rotator cuff tears in relatively equal proportions. The presence of an intramuscular cyst on MRI, although it may be an isolated finding, should prompt a thorough search of all the rotator cuff tendons for tears so that the patient may receive appropriate follow-up.

Comparison between T2-weighted MR and contrast-enhanced MR cholangiography in the evalutian of biliary anatomy in liver transplant donor candidates

Objective To compare conventional T2-weighted MR cholangiography (T2WI-MRC) with gadobenate dimeglumine enhanced T1-weighted MR cholangiography(CE-MRC) for evalution of biliary anatomy in liver transplant donor candidates. Methods Thirty-two healthy liver transplant donor candidates were examined with two MR cholangiogaphic methods. For T2WI-MRC, a three-dimensional turbo spin-echo sequence and oblique coronal heavily T2-weighted thick-slab turbo spin-echo imaging sequence were performed. For CE-MRC, three-dimensional fat-suppressed spoiled gradient-echo sequences were performed, with a time delay of 60 minutes following the administration of gadobenate dimeglumine. To compare the depiction of biliary duct anatomy and the artifact caused by intestinal liquid and breathing between the two methods. Intraoperative cholangiography was the reference-standard examination. Results The both methods depicted the biliary anatomy correctly in all 9 cases. The both methods showed the third branches of intrahepatic biliary duct clearly. T2WI-MRC showed interhepatic bihary duct before the third branches in 28 cases (87.5%), CE-MRC showed the same finding in 14 cases (43.8% ). T2WI-MRC showed common bile ducts intermitantly in 2 cases, which were normal in CE-MRC and intraoperative cholangiography. Intestinal liquid affected the image quality of biliary duct in 6 cases (18.8%) performed with T2WI-MRC, but none with CE-MRC. The artifacts caused by breathing were not obvious in the either method. Conclusion T2WI-MRC and CE-MRC both can be used to evaluate bihary anatomy of liver transplant donor candidates, but CE-MRC appears to be more accurate than T2WI-MRC. Key words: Liver transplantation; Contrast media; Magnetic resonance imaging; Comparative study

Precision and accuracy of low-dose CT protocols in the evaluation of skull landmarks

It was proposed to design a series of low-dose three-dimensional (3D) CT protocols with an effective dose similar to that of the conventional radiographic series (0.011-0.032 mSv) used to assess craniofacial asymmetry. It was then aimed to assess the precision and accuracy for skull landmarks recorded ex vivo using these CT protocols. Four ultra low-dose CT protocols (5 mAs, pitch 1.375/1.75; 10 mAs, pitch 1.375/1.75) were constructed on the basis of published data, dose calculations and measurements. A high-dose CT protocol was used as a reference standard examination. The protocols were used to scan a skull immersed in water. For each protocol, two observers evaluated 17 skull landmarks on two separate occasions. 3D and two-dimensional (2D) accuracy relative to the reference standard examination and inter- and intraobserver precision was calculated. The 2D accuracy was superior for the 10 mAs protocols and the 10 mAs/1.375 pitch protocol allowed one observer to achieve an accuracy of less than 2 mm for all landmarks. The 2D interrater precision for the 10 mAs/1.375 pitch protocol was superior to the other low-dose protocols and also the high-dose protocol, achieving precision less than 2 mm for 15/17 points. The 10 mAs protocols enabled greater 2D intrarater precision than the 5 mAs protocols for both observers. Using the 10 mAs/1.375 pitch CT protocol, it was possible to achieve 2D accuracy of less than 2 mm for almost all skull landmarks with an interrater precision similar to a high-dose CT protocol. Although the estimated effective dose of 0.035 mSv was slightly greater than that of the conventional radiographic series (0.011-0.032 mSv), there was the additional benefit of a 3D data set. The 10 mAs protocols allowed accuracy and precision superior to that of the 5 mAs protocols and hence they are more likely to be clinically applicable.

Pixel intensity and fractal analyses: detecting osteoporosis in perimenopausal and postmenopausal women by using digital panoramic images

Pixel intensity values (PI) and fractal dimensions (FD) were compared in selected mandibular regions on digital panoramic images of normal, osteopenic, and osteoporotic perimenopausal and postmenopausal women to evaluate their relative efficacies in detecting osteoporotic-associated bone density changes. Standardized mandibular angle, body, and canine/premolar (C/PM) regions on 54 charge-coupled device (CCD) digital panoramic images of normal and potentially osteoporotic postmenopausal women were analyzed for PI and FD. Lumbar spine and femoral neck dual-energy x-ray absorptiometry (DXA) on each patient served as the reference standard examination. Pearson correlation coefficients and analysis of variance (ANOVA) were performed. There was significant correlation among PI measurements (P < 0.01), and no significant correlation between FD. C/PM had significantly lower PI than control C/PM (P = 0.049). Osteoporotic changes in mandibular C/PM cancellous bone were detected in our study population on CCD digital panoramic images by using a robust image analysis paradigm. Future automated application of such image analysis could enable widespread, cost effective screening for osteoporosis in dental settings.

Prevalence of Diabetic Eye disease in Tayside, Scotland (P‐DETS) Study: methodology

To describe the use of a validated diabetes register for sampling frame generation and assessment of the representative nature of participants in a fieldwork study of diabetic eye disease. We performed an observational, cross-sectional fieldwork study of diabetic retinal disease using reference standard eye examination. We sampled the entire diabetic population using the Diabetes Audit and Research in Tayside Study (DARTS) diabetes register. The study population comprised 4825 diabetic patients aged over 16 years registered with one of 166 general practitioners (GPs) in 41 practices in Tayside in October 1999. This represented 61.1% of the Tayside diabetic population (7903). A total of 586 (66%; 95% confidence interval 63, 70) patients were examined from a sampling frame of 882 living patients registered with a Tayside GP. Demographic and disease parameters recorded on the DARTS patient register allowed comparison between participants and non-participants. This study shows the clear benefit of using a complete diabetic population as a sampling frame. This allows potential selection bias and external validity to be evaluated using routine data sources. Studies performed and reported in this way will aid the critical appraisal process.

Clinical Examination, Endosonography, and MR Imaging in Preoperative Assessment of Fistula in Ano: Comparison with Outcome-based Reference Standard

To prospectively evaluate the relative accuracy of digital examination, anal endosonography, and magnetic resonance (MR) imaging for preoperative assessment of fistula in ano by comparison to an outcome-derived reference standard. Ethical committee approval and informed consent were obtained. A total of 104 patients who were suspected of having fistula in ano underwent preoperative digital examination, 10-MHz anal endosonography, and body-coil MR imaging. Fistula classification was determined with each modality, with reviewers blinded to findings of other assessments. For fistula classification, an outcome-derived reference standard was based on a combination of subsequent surgical and MR imaging findings and clinical outcome after surgery. The proportion of patients correctly classified and agreement between the preoperative assessment and reference standard were determined with trend tests and kappa statistics, respectively. There was a significant linear trend (P < .001) in the proportion of fistula tracks (n = 108) correctly classified with each modality, as follows: clinical examination, 66 (61%) patients; endosonography, 87 (81%) patients; MR imaging, 97 (90%) patients. Similar trends were found for the correct anatomic classification of abscesses (P < .001), horseshoe extensions (P = .003), and internal openings (n = 99, P < .001); endosonography was used to correctly identify the internal opening in 90 (91%) patients versus 96 (97%) patients with MR imaging. Agreement between the outcome-derived reference standard and digital examination, endosonography, and MR imaging for classification of the primary track was fair (kappa = 0.38), good (kappa = 0.68), and very good (kappa = 0.84), respectively, and fair (kappa = 0.29), good (kappa = 0.64), and very good (kappa = 0.88), respectively, for classification of abscesses and horseshoe extensions combined. Endosonography with a high-frequency transducer is superior to digital examination for the preoperative classification of fistula in ano. While MR imaging remains superior in all respects, endosonography is a viable alternative for identification of the internal opening.

Quality assurance in screening for sight-threatening diabetic retinopathy.

There is a need for continuous evaluation of screening services for diabetic retinopathy against agreed performance standards. We describe a quality assurance programme implemented in Newcastle in January 1999 and report on outcomes at 18 months. Annual retinal screening is performed using combined retinal photography and direct ophthalmoscopy in two streams. Diabetologists perform screening in the Hospital Screening Programme, which serves patients whose diabetes is managed in specialist clinics, and trained retinal screeners perform screening in the District Screening Programme, which serves patients whose diabetes is managed in the community. Reference standard examination of dilated fundoscopy with a slit-lamp and condensing lens was performed by an ophthalmologist at periodic sessions on consecutive patients attending for screening. Six hundred and nine (6.4%) of 9468 patients screened underwent reference standard examination. The sensitivity and specificity of detection of sight-threatening diabetic retinopathy (STDR) was 82.5% and 98%, respectively, for the Hospital Screening Programme; 85.7% and 95.7%, respectively, for the District Screening Programme; and 83.3% and 96.8% for both services combined. One hundred and ten (18.1%) of 609 patients audited were referred to ophthalmology as a result of screening, and this led to 16 patients (2.6%) receiving laser photocoagulation for STDR. Reference standard examination identified a further four patients (0.7%) who required laser photocoagulation. Preliminary data indicate that satisfactory performance standards are being achieved. The National Service Framework for Diabetes requires that all units institute quality assurance for retinal screening, and we report the practical implementation of this in one district.

Color doppler ultrasound criteria to diagnose varicoceles: correlation of a new scoring system with physical examination

Objectives Color Doppler ultrasound (CDU) diagnostic criteria for varicoceles are poorly defined, and the role of CDU in diagnosing varicoceles is controversial. The purpose of this study is to assess the diagnostic accuracy of CDU for varicoceles compared to physical examination. Methods We prospectively studied 64 patients with CDU and collected the following data: maximum diameter of scrotal veins, the presence of a venous plexus, sum of the diameter of up to six veins of the plexus, and the duration and amplitude of flow change on Valsalva maneuver. To avoid interphysician variation, all patients were examined by one designated senior urologist with the sonographer remaining unaware of the findings. Results CDU parameters of 127 testis units in 64 patients were analyzed and compared to the physical findings. Fifty-nine testis units were positive and 57 units were negative for varicocele on physical examination. In 11 testis units, results of physical examination were inconclusive regarding the presence of varicocele. The commonly accepted CDU criterion for varicocele (maximal vein diameter of 3 mm or greater) had a sensitivity of 53% and specificity of 91% compared to physical examination. We developed a new scoring system incorporating the maximal venous diameter (score 0 to 3), the presence of a venous plexus and the sum of the diameters of veins in the plexus (score 0 to 3), and the change of flow on Valsalva maneuver (score 0 to 3). Using a total score of 4 or more to define the presence of CDU-positive varicocele, we observed a sensitivity of 93% and a specificity of 85% when compared to physical examination. All moderate to large varicoceles found on physical examination were positive by CDU diagnosis using the scoring system, but the same group had only a 68% positive rate by traditional CDU diagnostic criteria. Conclusions Using the proposed new scoring system, CDU has been shown to be a reliable and accurate method of diagnosis for varicoceles compared to the current reference standard physical examination. CDU has the advantages of being able to objectively examine venous plexus and measure blood flow parameters and to be less observer-dependent than physical examination. UROLOGY 50: 953-956, 1997.