Ultrasound evaluation of varicoceles: systematic literature review and rationale of the ESUR-SPIWG Guidelines and Recommendations

Abstract

Although often asymptomatic and detected incidentally, varicocele is a relatively common problem in patients who seek medical attention for infertility problems. Ultrasound (US) is the imaging modality of choice for evaluation, but there is no consensus on the diagnostic criteria, classification, and examination technique. In view of this uncertainty, the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology (ESUR-SPIWG) undertook a systematic review of the available literature on this topic, to use as the basis for evidence-based guidelines and recommendations. This paper provides the results of the systematic review on which guidelines were constructed.

Keywords: Doppler studies; Infertility; US; Varicocele.

Fig.1

Grey-scale appearance of varicocele. Multiple, hypoechoic serpiginous dilated veins (arrowheads) larger than 3 mm containing low-level internal echoes

Fig.2

Spectral Doppler analysis in varicocele. Changes of reflux while standing during Valsalva (arrowhead). a Flow inversion. b Flow increase showing a plateau throughout Valsalva. In both cases reflux persists for more than 2 s

Fig.3

Sarteschi’s grade I varicocele. Colour Doppler images obtained at rest (a) and during Valsalva (b) showing dilated veins of the spermatic cord with reflux during Valsalva at the inguinal canal

Fig.4

Sarteschi’s grade II varicocele. Colour Doppler images obtained at rest (a) and during Valsalva (b) showing dilated veins in the supratesticular region with reflux during Valsalva (T = testis)

Fig.5

Sarteschi’s grade III varicocele. Colour Doppler images obtained at rest (a) and during Valsalva (b) showing dilated veins to the inferior pole of the testis (T) with reflux during Valsalva

Fig.6

Sarteschi’s grade IV varicocele. Colour Doppler images obtained in supine position at rest (a) and while standing during Valsalva (b). Dilated veins with reflux are visible also at rest. Reflux increases while standing during Valsalva (T = testis)

Fig.7

Secondary varicocele in an 85-year-old patient presenting with a right scrotal lump. a Colour Doppler ultrasound of the right spermatic cord shows markedly dilated pampiniform plexus with basal reflux. b Spectral Doppler interrogation obtained in an upright position shows no changes during Valsalva’s maneuver (arrowhead). c Ultrasound interrogation of the right kidney shows a large renal tumour. d Contrast-CT scanning showing a large right renal tumour growing into the right renal vein (curved arrow) and inferior vena cava (asterisks)