Levels of evidence
1a
Evidence obtained from meta-analysis of randomized trials
1b
Evidence obtained from at least one randomized trial
2a
Evidence obtained from one well-designed controlled study without randomization
2b
Evidence obtained from at least one other type of well-designed quasi-experimental study
3
Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
4
Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
Rating scheme for the grade of recommendations
A
Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
B
Based on well-conducted clinical studies, but without randomized clinical trials
C
Made despite the absence of directly applicable clinical studies of good quality
Guidelines statements are not intended to be used as a ‘legal standard’ against which physicians should be measured but rather serve to provide a framework of standardized care while maintaining clinical autonomy and physician judgment. Although guidelines are intended to offer advantages in standardization of care, improvement in efficiency, enhanced research opportunities, and creation of a cost-effective diagnosis/treatment algorithm, many physicians opt not to adopt guidelines for various reasons, including financial, technical and personal factors. Despite these limitations, a combination of a guideline-based management combined with physician judgment is likely to represent the most prevailing standard of care [304].
Diagnosis
AUA and ASRM Guidelines
According to the AUA and ASRM, a palpable varicocele can be detected in infertile men in erect position and feels like a “bag of worms” and it disappears or very significantly diminishes in size when the patient is recumbent. If the varicocele is not clearly palpable, a repeat examination is advised in erect position with Valsalva maneuver.
Only clinically-palpable varicoceles have been evidently associated with infertility. Varicoceles are characteristically graded on a scale of 1–3, in which grade 3 is visually inspected, grade 2 is easily palpable, and grade 1 is only palpable with Valsalva maneuver [185]. These definitions are rather equivocal and subjective definitions, as what may be easily palpable to one examiner may not be for another. However, there is agreement that varicoceles palpable by most examiners are considered “clinically significant.”
Ancillary diagnostic measures, such as scrotal ultrasonography, thermography, Doppler examination, radionuclide scanning, and spermatic venography, should not be used for routine screening and detection of subclinical varicoceles in patients without a palpable abnormality.
Scrotal ultrasonography is indicated for evaluation of a questionable physical examination of the scrotum. Although decisive evidence-based criteria for diagnosis of varicocele are lacking, the current consensus agrees that multiple spermatic veins > 2.5–3.0 mm in diameter (at rest and with Valsalva) tend to correlate with the presence of clinically-significant varicoceles [186].
In persistent and recurrent varicocele after surgical repair, spermatic venography is useful to demonstrate the anatomic position of refluxing spermatic veins. Although early studies did not demonstrate a difference in outcome based on varicocele size, more recent data suggest that larger varicoceles may have a greater impact on semen parameters, and correction may result in greater improvement [224].
EAU Guidelines
The EAU guidelines recommends that diagnosis of varicocele is initially made by clinical examination and should be confirmed by color Doppler analysis in the supine and upright position [185, 302].
In children and adolescents, the size of the testis should be evaluated during palpation to detect a smaller testis. To discriminate testicular hypoplasia, the testicular volume is measured by ultrasound examination or by orchidometer. In adolescents, a testis that is smaller by more than 2 mL or 20 % compared to the other testis is considered to be hypoplastic [121] (Level of evidence 2). In order to assess testicular injury in adolescents with varicocele, supranormal follicle-stimulating hormone (FSH) and luteinizing hormone (LH) responses to the luteinizing hormone-releasing hormone (LHRH) stimulation test are considered reliable, because histopathological testicular changes have been found in these patients [254, 305].
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