Varicocoele. Classification and pitfalls

Abstract Background Varicocoeles have been considered for a long time potentially correctable causes for male infertility, even though the correlation of this condition with infertility and sperm damage is still debated. Objective To present a summary of the evidence evaluation for imaging varicocoeles, to underline the need for a standardized examination technique and for a unique classification, and to focus on pitfalls in image interpretation. Methods Based on the evidence of the literature, the current role of ultrasound (US) imaging for varicocoeles has been reported and illustrated, with emphasis on examination technique, classification, and pitfalls. Results US is the imaging modality of choice. It is widely used in Europe, while in other countries clinical classification of varicocoeles is considered sufficient to manage the patient. A number of US classifications exist for varicocoeles, in which the examinnation is performed in different ways. Discussion An effort toward standardization is mandatory, since lack of standardization contributes to the confusion of the available literature, and has a negative impact on the understanding of the role itself of imaging in patients with varicocoeles. Conclusion Use of the Sarteschi/Liguori classification for varicocoeles is recommended, since it is the most complete and widely used US scoring system available today. Tubular extratesticular structures resembling varicocoeles, either at palpation or at US, should be identified and correctly characterized.

moted by the European Academy of Andrology 3,4 reported in healthy, fertile men a prevalence of varicocoeles (∼37%) similar to that reported in primary infertile men. [5][6][7] These data suggest that varicocoele may exert a scanty effect on male fertility, and that its surgical correction should be limited to highly selected populations. Accordingly, current EAU Guidelines on Male Infertility support nowadays very specific indications for varicocoele treatment both in adults and adolescents. 8 Ultrasound (US) is the imaging modality of choice for varicocoeles. 8 The body of published investigations is large, but exceedingly heterogeneous, and the role of imaging itself in the management of these patients is debated. 9,10 Outside Europe, US is not routinely used. Most important, both in and outside Europe US is performed in different ways, and several classifications are used. 2 Recently, ESUR-SPIWG -the Scrotal and Penile Imaging Working group of the European Society of Urogenital Radiology -released two papers to promote standardization of US for varicocoeles. 5,6 Recommendations are based on the evidence of the available literature and, when evidence is lacking, on best clinical practice and expert opinion. In these two papers, the most important features to consider when investigating a patient for varicocoeles are discussed, how to perform the US examination, and which classification is best.

Clinical classification of varicocoeles
Association between infertility, ipsilateral testicular atrophy, and varicocoeles regards clinically palpable, rather than non-palpable disease. 11 According to the criteria introduced in 1970 by Dubin and Amelar, varicocoeles are detected and scored clinically in three grades. 12
Use of the Sarteschi/Liguori classification is recommended. 24,25 This is the most complete and widely used classification available today

How to perform US examination for varicocoeles
Gray-scale, color Doppler, and spectral analysis have to be done.
All parameters should be assessed bilaterally. The patient should be evaluated in both the supine and upright position, in general,  In varicocoeles, venous reflux is related with testicular hypotrophy, and repair can result in an increase of the testicular volume. [26][27][28] In testis, volume is obtained more accurately from measurement of the three diameters at US rather than using an orchidometer, or

Pitfalls
Another mimic for varicocoele could be Zinner syndrome. 42 The dilated vas deferens and epididymis can simulate venous dilatation, and during the Valsalva maneuver a Doppler signal resembling reflux can be artefactually recorded, due to spermatozoa movement.

Intratesticular varicocoeles can resemble lesions when investigated
in the supine position at rest, but reveal their vascular nature when the patient is investigated in standing position during Valsalva manoeuver ( Figure 9). Venous reflux is identified, a feature that allows differentiation with other vascular intratesticular lesions, such haemangiomas and arteriovenous malformations, which show arterial flows and arterialized-venous spectral waveform. 5

CONCLUSIONS
Although they are often asymptomatic and detected incidentally, varicocoeles are considered potentially correctable causes for male infertility. Diagnosis is obtained by US, but standardization is necessary, since there is no consensus on the diagnostic criteria, classification, and examination technique. The Sarteschi/Liguori classification is the most complete and widely used scoring system available today. Cysts, spermatoceles, tubular ectasia, post-vasectomy changes, and other conditions which can mimic clinically varicocoeles are differentiated with multiparametric US.

CONFLICT OF INTEREST
All authors declare that they have no conflict of interest

AUTHOR CONTRIBUTIONS
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