Ultrasound evaluation of varicoceles: guidelines and recommendations of the European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) for detection, classification, and grading

  • Simon FreemanEmail author
  • Michele Bertolotto
  • Jonathan Richenberg
  • Jane Belfield
  • Vikram Dogra
  • Dean Y. Huang
  • Francesco Lotti
  • Karolina Markiet
  • Olivera Nikolic
  • Subramaniyan Ramanathan
  • Parvati Ramchandani
  • Laurence Rocher
  • Mustafa Secil
  • Paul S. Sidhu
  • Katarzyna Skrobisz
  • Michal Studniarek
  • Athina Tsili
  • Ahmet Tuncay Turgut
  • Pietro Pavlica
  • Lorenzo E. Derchi
  • members of the ESUR-SPIWG WG


Varicoceles are relatively common particularly in asymptomatic men and are even more prevalent in subfertile men, representing the most common potentially correctable cause of male infertility. Ultrasound (US) is the imaging modality of choice for varicocele evaluation, but there is no widely accepted consensus on examination technique, diagnostic criteria, or classification. In view of this uncertainty, the guideline writing group (WG) of the European Society of Urogenital Radiology (ESUR) Scrotal and Penile Imaging Working Group (ESUR-SPIWG) undertook a literature review and assessment of the quality of relevant evidence. The group then produced evidence-based recommendations for varicocele US examination, interpretation, and classification by consensus agreement. The results are presented in the form of 15 clinical questions with a brief summary of the relevant evidence and the authorised recommendations from the SPIWG. This paper provides a short summary of the evidence evaluation and the complete recommendations.

Key Points

• Varicocele is a common clinical problem; it is highly prevalent amongst subfertile men and the most common potentially correctable cause of male infertility.

• Ultrasound is the imaging modality of choice for varicocele assessment, but there is no generally agreed consensus on the US examination technique or the criteria that should be used for diagnosis, grading, and classification.

• This paper summarises the recommendations of the ESUR-SPIWG for standardising the US assessment of varicoceles. This includes examination technique, image interpretation, classification, and reporting.


Varicocele Scrotum Infertility, male Ultrasonography Ultrasonography, Doppler 



Appraisal of Guidelines for Research and Evaluation


Arteriovenous malformations


European Society of Urogenital Radiology


Grading of Recommendations Assessment, Development and Evaluation






Oxford Centre for Evidence Based Medicine


Patient Problem (or Population), Intervention, Comparison or Control, Outcome




Scrotal and Penile Imaging Working Group






Guideline writing group



The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Dr. Simon Freeman on behalf of the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology (ESUR-SPIWG).

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was not required for this study because this paper provides a summary of available evidence and expert opinion; no new studies on patients were involved.

Ethical approval

Institutional Review Board approval was not required because this is an evidence summary and expert recommendation paper. No new studies on human patients were undertaken specifically for this paper.

Study subjects or cohorts overlap

All previous studies cited as evidence in this paper are acknowledged in the references.


• Multicentre authored paper on behalf of the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology (ESUR-SPIWG). Literature review, evidence summary, and expert recommendations.


  1. 1.
    Paick S, Choi WS (2019) Varicocele and testicular pain: a review. World J Mens Health 37(1):4–11CrossRefPubMedGoogle Scholar
  2. 2.
    Dubin L, Amelar RD (1970) Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Fertil Steril 21(8):606–609CrossRefPubMedGoogle Scholar
  3. 3.
    Practice Committee of the American Society for Reproductive Medicine; Society for Male Reproduction and Urology (2014) Report on varicocele and infertility: a committee opinion. Fertil Steril 102(6):1556–1560CrossRefGoogle Scholar
  4. 4.
    Khera M, Lipshultz LI (2008) Evolving approach to the varicocele. Urol Clin North Am 35(2):183–189CrossRefPubMedGoogle Scholar
  5. 5.
    Zini A, Dohle G (2011) Are varicoceles associated with increased deoxyribonucleic acid fragmentation? Fertil Steril 96(6):1283–1287CrossRefPubMedGoogle Scholar
  6. 6.
    Jungwirth A, Giwercman A, Tournaye H et al (2012) European Association of Urology guidelines on male infertility: the 2012 update. Eur Urol 62(2):324–332CrossRefPubMedGoogle Scholar
  7. 7.
    Agarwal A, Deepinder F, Cocuzza M et al (2007) Efficacy of varicocelectomy in improving semen parameters: new meta-analytical approach. Urology. 70(3):532–538CrossRefPubMedGoogle Scholar
  8. 8.
    Brouwers MC, Kho ME, Browman GP et al (2010) AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 182(18):E839–E842CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    van der Molen AJ, Reimer P, Dekkers IA et al (2018) Post-contrast acute kidney injury - Part 1: definition, clinical features, incidence, role of contrast medium and risk factors : recommendations for updated ESUR Contrast Medium Safety Committee guidelines. Eur Radiol 28(7):2845–2855CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Guyatt GH, Oxman AD, Kunz R et al (2011) GRADE guidelines: 2. Framing the question and deciding on important outcomes. J Clin Epidemiol 64(4):395–400CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Medicine OCfE-B. The Oxford 2011 Levels of Evidence 2011 Available from: Accessed April 2019
  12. 12.
    Plus EE. GRADE: Grading of Recommendations Assessment, Development and Evaluation (A, B, C, D): John Wiley & Sons, Inc; 2018. Available from: Accessed April 2019
  13. 13.
    Dalkey N, Helmer O (1963) An experimental application of the DELPHI method to the use of experts. Manag Sci 9(3):458–467CrossRefGoogle Scholar
  14. 14.
    Jungwirth A, Diemer T, Kopa Z, Krausz C, Minhas S, Tournaye H (2018) Guidelines on male infertility, European Association of Urology. EAU Guidelines Office, Arnhem. Available from: Accessed April 2019
  15. 15.
    Saypol DC (1981) Varicocele. J Androl 2(2):61–71CrossRefGoogle Scholar
  16. 16.
    Alsaikhan B, Alrabeeah K, Delouya G, Zini A (2016) Epidemiology of varicocele. Asian J Androl 18(2):179–181CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Dubin L, Amelar RD (1971) Etiologic factors in 1294 consecutive cases of male infertility. Fertil Steril 22(8):469–474CrossRefPubMedGoogle Scholar
  18. 18.
    Kibar Y, Seckin B, Erduran D (2002) The effects of subinguinal varicocelectomy on Kruger morphology and semen parameters. J Urol 168(3):1071–1074CrossRefPubMedGoogle Scholar
  19. 19.
    Zini A, Boman JM (2009) Varicocele: red flag or red herring? Semin Reprod Med 27(2):171–178CrossRefPubMedGoogle Scholar
  20. 20.
    Liguori G, Trombetta C, Garaffa G et al (2004) Color Doppler ultrasound investigation of varicocele. World J Urol 22(5):378–381CrossRefPubMedGoogle Scholar
  21. 21.
    Marmar JL (2001) Varicocele and male infertility: Part II: the pathophysiology of varicoceles in the light of current molecular and genetic information. Hum Reprod Update 7(5):461–472CrossRefPubMedGoogle Scholar
  22. 22.
    Will MA, Swain J, Fode M, Sonksen J, Christman GM, Ohl D (2011) The great debate: varicocele treatment and impact on fertility. Fertil Steril 95(3):841–852CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Naughton CK, Nangia AK, Agarwal A (2001) Varicocele and male infertility: Part II: pathophysiology of varicoceles in male infertility. Hum Reprod Update 7(5):473–481CrossRefPubMedGoogle Scholar
  24. 24.
    Papanikolaou F, Chow V, Jarvi K, Fong B, Ho M, Zini A (2000) Effect of adult microsurgical varicocelectomy on testicular volume. Urology. 56(1):136–139CrossRefPubMedGoogle Scholar
  25. 25.
    Jung A, Schuppe HC (2007) Influence of genital heat stress on semen quality in humans. Andrologia. 39(6):203–215CrossRefPubMedGoogle Scholar
  26. 26.
    Evers JH, Collins J, Clarke J (2008) Surgery or embolisation for varicoceles in subfertile men. Cochrane Database Syst Rev 2008(3):CD000479. CrossRefGoogle Scholar
  27. 27.
    Kroese AC, De Lange NM, Collins JA, Evers JL (2013) Varicocele surgery, new evidence. Hum Reprod Update 19(4):317CrossRefPubMedGoogle Scholar
  28. 28.
    Kroese ACJ, de Lange NM, Collins J, Evers JL (2012) Surgery or embolization for varicoceles in subfertile men. Cochrane Database Syst Rev (10):CD000479.
  29. 29.
    Smit M, Romijn JC, Wildhagen MF, Veldhoven JL, Weber RF, Dohle GR (2010) Decreased sperm DNA fragmentation after surgical varicocelectomy is associated with increased pregnancy rate. J Urol 183(1):270–274CrossRefPubMedGoogle Scholar
  30. 30.
    Baazeem A, Belzile E, Ciampi A et al (2011) Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair. Eur Urol 60(4):796–808CrossRefPubMedGoogle Scholar
  31. 31.
    Macleod R, Biyani CS, Cartledge J, Eardley I (2015) Varicocele. BMJ Clin Evid 2015Google Scholar
  32. 32.
    Kim KH, Lee JY, Kang DH, Lee H, Seo JT, Cho KS (2013) Impact of surgical varicocele repair on pregnancy rate in subfertile men with clinical varicocele and impaired semen quality: a meta-analysis of randomized clinical trials. Korean J Urol 54(10):703–709CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Fertility: assessment and treatment for people with fertility problems. National Institute for Health and Clinical Excellence: Guidance [CG11]. London (UK) 2004. Accessed April 2019
  34. 34.
    Lotti F, Maggi M (2014) Ultrasound of the male genital tract in relation to male reproductive health. Hum Reprod Update 21(1):56–83CrossRefPubMedGoogle Scholar
  35. 35.
    Hirsh AV, Cameron KM, Tyler JP, Simpson J, Pryor JP (1980) The Doppler assessment of varicoceles and internal spermatic vein reflux in infertile men. Br J Urol 52(1):50–56CrossRefPubMedGoogle Scholar
  36. 36.
    Dhabuwala CB, Kumar AB, Kerkar PD, Bhutawala A, Pierce J (1989) Patterns of Doppler recordings and its relationship to varicocele in infertile men. Int J Androl 12(6):430–438CrossRefPubMedGoogle Scholar
  37. 37.
    Sarteschi LM, Paoli R, Bianchini M, Menchini Fabris GF (1993) Lo studio del varicocele con eco-color-Doppler. G Ital Ultrasonologia 4(2):43–49Google Scholar
  38. 38.
    Hoekstra T, Witt MA (1995) The correlation of internal spermatic vein palpability with ultrasonographic diameter and reversal of venous flow. J Urol 153(1):82–84CrossRefPubMedGoogle Scholar
  39. 39.
    Chiou RK, Anderson JC, Wobig RK et al (1997) Color Doppler ultrasound criteria to diagnose varicoceles: correlation of a new scoring system with physical examination. Urology. 50(6):953–956CrossRefPubMedGoogle Scholar
  40. 40.
    Cornud F, Belin X, Amar E, Delafontaine D, Helenon O, Moreau JF (1999) Varicocele: strategies in diagnosis and treatment. Eur Radiol 9(3):536–545CrossRefPubMedGoogle Scholar
  41. 41.
    Oyen RH (2002) Scrotal ultrasound. Eur Radiol 12(1):19–34CrossRefPubMedGoogle Scholar
  42. 42.
    Pauroso S, Di Leo N, Fulle I, Di Segni M, Alessi S, Maggini E (2011) Varicocele: ultrasonographic assessment in daily clinical practice. J Ultrasound 14(4):199–204CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Iosa G, Lazzarini D (2013) Hemodynamic classification of varicoceles in men: our experience. J Ultrasound 16(2):57–63CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Patil V, Shetty SC, Das SK (2016) Redefining the criteria for grading varicoceles based on reflux times: a clinicoradiological correlation. Ultrasound Q 32(1):82–85CrossRefPubMedGoogle Scholar
  45. 45.
    Wolverson MK, Houttuin E, Heiberg E, Sundaram M, Gregory J (1983) High-resolution real-time sonography of scrotal varicocele. AJR Am J Roentgenol 141(4):775–779CrossRefPubMedGoogle Scholar
  46. 46.
    Gonda RL Jr, Karo JJ, Forte RA, O'Donnell KT (1987) Diagnosis of subclinical varicocele in infertility. AJR Am J Roentgenol 148(1):71–75CrossRefPubMedGoogle Scholar
  47. 47.
    Orda R, Sayfan J, Manor H, Witz E, Sofer Y (1987) Diagnosis of varicocele and postoperative evaluation using inguinal ultrasonography. Ann Surg 206(1):99–101CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    McClure RD, Khoo D, Jarvi K, Hricak H (1991) Subclinical varicocele: the effectiveness of varicocelectomy. J Urol 145(4):789–791CrossRefPubMedGoogle Scholar
  49. 49.
    Eskew LA, Watson NE, Wolfman N, Bechtold R, Scharling E, Jarow JP (1993) Ultrasonographic diagnosis of varicoceles. Fertil Steril 60(4):693–697CrossRefPubMedGoogle Scholar
  50. 50.
    Pilatz A, Altinkilic B, Kohler E, Marconi M, Weidner W (2011) Color Doppler ultrasound imaging in varicoceles: is the venous diameter sufficient for predicting clinical and subclinical varicocele? World J Urol 29(5):645–650CrossRefPubMedGoogle Scholar
  51. 51.
    Jarow JP, Ogle SR, Eskew LA (1996) Seminal improvement following repair of ultrasound detected subclinical varicoceles. J Urol 155(4):1287–1290CrossRefPubMedGoogle Scholar
  52. 52.
    Schiff JD, Li PS, Goldstein M (2006) Correlation of ultrasound-measured venous size and reversal of flow with Valsalva with improvement in semen-analysis parameters after varicocelectomy. Fertil Steril 86(1):250–252CrossRefPubMedGoogle Scholar
  53. 53.
    Karami M, Mazdak H, Khanbabapour S, Adibi A, Nasr N (2014) Determination of the best position and site for color Doppler ultrasonographic evaluation of the testicular vein to define the clinical grades of varicocele ultrasonographically. Adv Biomed Res 3:17CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Kim YS, Kim SK, Cho IC, Min SK (2015) Efficacy of scrotal Doppler ultrasonography with the Valsalva maneuver, standing position, and resting-Valsalva ratio for varicocele diagnosis. Korean J Urol 56(2):144–149CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Cina A, Minnetti M, Pirronti T et al (2006) Sonographic quantitative evaluation of scrotal veins in healthy subjects: normative values and implications for the diagnosis of varicocele. Eur Urol 50(2):345–350CrossRefPubMedGoogle Scholar
  56. 56.
    Metin A, Bulut O, Temizkan M (1991) Relationship between the left spermatic vein diameter measured by ultrasound and palpated varicocele and Doppler ultrasound findings. Int Urol Nephrol 23(1):65–68CrossRefPubMedGoogle Scholar
  57. 57.
    Zampieri N, Cervellione RM (2008) Varicocele in adolescents: a 6-year longitudinal and followup observational study. J Urol 180(4):1653–1656CrossRefPubMedGoogle Scholar
  58. 58.
    Zhou T, Zhang W, Chen Q et al (2015) Effect of varicocelectomy on testis volume and semen parameters in adolescents: a meta-analysis. Asian J Androl 17(6):1012–1016CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Sakamoto H, Saito K, Ogawa Y, Yoshida H (2008) Effects of varicocele repair in adults on ultrasonographically determined testicular volume and on semen profile. Urology. 71(3):485–489CrossRefPubMedGoogle Scholar
  60. 60.
    Cornud F, Amar E, Hamida K, Thiounn N, Helenon O, Moreau JF (2000) Imaging in male hypofertility and impotence. BJU Int 86:153–163CrossRefPubMedGoogle Scholar
  61. 61.
    Goede J, Hack WW, Sijstermans K et al (2011) Normative values for testicular volume measured by ultrasonography in a normal population from infancy to adolescence. Horm Res Paediatr 76(1):56–64CrossRefPubMedGoogle Scholar
  62. 62.
    Kim ED, Lipshultz LI (1996) Role of ultrasound in the assessment of male infertility. J Clin Ultrasound 24(8):437–453CrossRefPubMedGoogle Scholar
  63. 63.
    Condorelli R, Calogero AE, La Vignera S (2013) Relationship between testicular volume and conventional or nonconventional sperm parameters. Int J Endocrinol 2013:6CrossRefGoogle Scholar
  64. 64.
    Tijani KH, Oyende BO, Awosanya GO, Ojewola RW, Yusuf AO (2014) Assessment of testicular volume: a comparison of fertile and sub-fertile West African men. Afr J Urol 20(3):136–140CrossRefGoogle Scholar
  65. 65.
    Sakamoto H, Ogawa Y, Yoshida H (2008) Relationship between testicular volume and testicular function: comparison of the Prader orchidometric and ultrasonographic measurements in patients with infertility. Asian J Androl 10(2):319–324CrossRefPubMedGoogle Scholar
  66. 66.
    Sakamoto H, Yajima T, Nagata M, Okumura T, Suzuki K, Ogawa Y (2008) Relationship between testicular size by ultrasonography and testicular function: measurement of testicular length, width, and depth in patients with infertility. Int J Urol 15(6):529–533CrossRefPubMedGoogle Scholar
  67. 67.
    Lambert B (1951) The frequency of mumps and of mumps orchitis and the consequences for sexuality and fertility. Acta Genet Stat Med 2(Suppl. 1:1–166PubMedGoogle Scholar
  68. 68.
    Mbaeri TU, Orakwe JC, Nwofor AME, Oranusi CK, Mbonu OO (2013) Ultrasound measurements of testicular volume: comparing the three common formulas with the true testicular volume determined by water displacement. Afr J Urol 19(2):69–73CrossRefGoogle Scholar
  69. 69.
    Sakamoto H, Saito K, Oohta M, Inoue K, Ogawa Y, Yoshida H (2007) Testicular volume measurement: comparison of ultrasonography, orchidometry, and water displacement. Urology. 69(1):152–157CrossRefPubMedGoogle Scholar
  70. 70.
    Liguori G, Trombetta C, Ollandini G et al (2009) Predictive factors of better improvement in semen quality after sclerotization of varicocele: preliminary report. J Androl Sci 16:47–53Google Scholar
  71. 71.
    Abdel-Meguid TA, Al-Sayyad A, Tayib A, Farsi HM (2011) Does varicocele repair improve male infertility? An evidence-based perspective from a randomized, controlled trial. Eur Urol 59(3):455–461CrossRefPubMedGoogle Scholar
  72. 72.
    Liguori G, Ollandini G, Pomara G et al (2010) Role of renospermatic basal reflow and age on semen quality improvement after sclerotization of varicocele. Urology. 75(5):1074–1078CrossRefPubMedGoogle Scholar
  73. 73.
    Cornud F, Amar E, Hamida K, Helenon O, Moreau JF (2001) Ultrasound findings in male hypofertility and impotence. Eur Radiol 11(11):2126–2136CrossRefPubMedGoogle Scholar
  74. 74.
    Kocakoc E, Serhatlioglu S, Kiris A, Bozgeyik Z, Ozdemir H, Bodakci MN (2003) Color Doppler sonographic evaluation of inter-relations between diameter, reflux and flow volume of testicular veins in varicocele. Eur Radiol 47(3):251–256CrossRefGoogle Scholar
  75. 75.
    Kozakowski KA, Gjertson CK, Decastro GJ, Poon S, Gasalberti A, Glassberg KI (2009) Peak retrograde flow: a novel predictor of persistent, progressive and new onset asymmetry in adolescent varicocele. J Urol 181(6):2717–2722CrossRefPubMedGoogle Scholar
  76. 76.
    Tasci AI, Resim S, Caskurlu T, Dincel C, Bayraktar Z, Gurbuz G (2001) Color Doppler ultrasonography and spectral analysis of venous flow in diagnosis of varicocele. Eur Urol 39(3):316–321CrossRefPubMedGoogle Scholar
  77. 77.
    Mohseni MJ, Nazari H, Amini E et al (2011) Shunt-type and stop-type varicocele in adolescents: prognostic value of these two different hemodynamic patterns. Fertil Steril 96(5):1091–1096CrossRefPubMedGoogle Scholar
  78. 78.
    Glassberg KI (2014) My indications for treatment of the adolescent varicocele (and why?). Trans Androl Urol 3(4):402–412Google Scholar
  79. 79.
    Paduch DA, Niedzielski J (1997) Repair versus observation in adolescent varicocele: a prospective study. J Urol 158(3):1128–1132CrossRefPubMedGoogle Scholar
  80. 80.
    Poon SA, Gjertson CK, Mercado MA, Raimondi PM, Kozakowski KA, Glassberg KI (2010) Testicular asymmetry and adolescent varicoceles managed expectantly. J Urol 183(2):731–734CrossRefPubMedGoogle Scholar
  81. 81.
    Morteza T, Ehsan A (2016) Quantitative Doppler assessment of flow characteristics in pampiniform venous plexus, in patients with varicocele: is there any relationship with semen analysis? PJR. 20(3):121–124Google Scholar
  82. 82.
    Van Batavia JP, Badalato G, Fast A, Glassberg KI (2013) Adolescent varicocele-is the 20/38 harbinger a durable predictor of testicular asymmetry? J Urol 189(5):1897–1902CrossRefPubMedGoogle Scholar
  83. 83.
    Hsu HS, Chang LS, Cheng MT, Wei YH (1994) Decreased blood flow and defective energy metabolism in the varicocele-bearing testicles of rats. Eur Urol 25:71–75CrossRefPubMedGoogle Scholar
  84. 84.
    Zhang M, Du L, Liu Z, Qi H, Chu Q (2014) The effects of varicocelectomy on testicular arterial blood flow: laparoscopic surgery versus microsurgery. Urol J 11(5):1900–1906PubMedGoogle Scholar
  85. 85.
    Grasso FL, Pepe P, Panella P, Pepe F (1997) Volocimetric evaluation of spermatic vessels with echo color Doppler in patients with idiopathic varicocele. Minerva Urol Nefrol 49(4):179–182Google Scholar
  86. 86.
    Ross JA, Watson JN Jr, Jarow JP (1994) The effect of varicoceles on testicular blood flow in man. Urology. 44(4):535–539CrossRefPubMedGoogle Scholar
  87. 87.
    Akcar N, Turgut M, Adapinar B, Ozkan IR (2004) Intratesticular arterial resistance and testicular volume in infertile men with subclinical varicocele. J Clin Ultrasound 32(8):389–393CrossRefPubMedGoogle Scholar
  88. 88.
    Tarhan S, Gumus B, Gunduz I, Ayyildiz V, Goktan C (2003) Effect of varicocele on testicular artery blood flow in men color Doppler investigation. Scand J Urol Nephrol 37(1):38–42CrossRefPubMedGoogle Scholar
  89. 89.
    Biagiotti G, Cavallini G, Modenini F, Vitali G, Gianaroli L (2002) Spermatogenesis and spectral echo-colour Doppler traces from the main testicular artery. BJU Int 90(9):903–908CrossRefPubMedGoogle Scholar
  90. 90.
    Unsal A, Turgut AT, Taskin F, Kosar U, Karaman CZ (2007) Resistance and pulsatility index increase in capsular branches of testicular artery: indicator of impaired testicular microcirculation in varicocele? J Clin Ultrasound 35(4):191–195CrossRefPubMedGoogle Scholar
  91. 91.
    Baigorri BF, Dixon RG (2016) Varicocele: a review. Semin Intervent Radiol 33(3):170–176CrossRefPubMedPubMedCentralGoogle Scholar
  92. 92.
    (1985) Comparison among different methods for the diagnosis of varicocele. World Health Organisation.. Fertil Steril 43(4):575–582Google Scholar
  93. 93.
    Cariati M, Pieri S, Agresti P et al (2012) Diagnosis of right-sided varicocele: a retrospective comparative study between clinical examination, Doppler findings, US imaging and vascular anatomy at phlebography. Eur J Radiol 81(9):1998–2006CrossRefPubMedGoogle Scholar
  94. 94.
    DeCastro GJ, Shabsigh A, Poon SA, Laor L, Glassberg KI (2009) Adolescent varicocelectomy - is the potential for catch-up growth related to age and/or Tanner stage? J Urol 181(1):322–327CrossRefPubMedGoogle Scholar
  95. 95.
    Gat Y, Bachar GN, Zukerman Z, Belenky A, Gorenish M (2004) Physical examination may miss the diagnosis of bilateral varicocele: a comparative study of 4 diagnostic modalities. J Urol 172(4):1414–1417CrossRefPubMedGoogle Scholar
  96. 96.
    Pfeiffer D, Berger J, Schoop C, Tauber R (2006) A Doppler-based study on the prevalence of varicocele in German children and adolescents. Andrologia. 38(1):13–19CrossRefPubMedGoogle Scholar
  97. 97.
    Preziosi P, Miano R, Bitelli M, Ciolfi MG, Micali S, Micali F (2001) Right varicocele associated with inferior vena cava malformation in situs inversus: percutaneous treatment with retrograde sclerotherapy. J Endourol 15(10):1001–1003CrossRefPubMedGoogle Scholar
  98. 98.
    Ding H, Tian J, Du W, Zhang L, Wang H, Wang Z (2012) Open non-microsurgical, laparoscopic or open microsurgical varicocelectomy for male infertility: a meta-analysis of randomized controlled trials. BJU Int 110(10):1536–1542CrossRefPubMedGoogle Scholar
  99. 99.
    Cervellione RM, Corroppolo M, Bianchi A (2008) Subclinical varicocele in the pediatric age group. J Urol 179(2):717–719CrossRefPubMedGoogle Scholar
  100. 100.
    Zampieri N, Dall’Agnola A (2011) Subclinical varicocele and sports: a longitudinal study. Urology. 77(5):1199–1202CrossRefPubMedGoogle Scholar
  101. 101.
    Diamond DA (2007) Adolescent varicocele. Curr Opin Urol 17(4):263–267CrossRefPubMedGoogle Scholar
  102. 102.
    Cvitanic OA, Cronan JJ, Sigman M, Landau ST (1993) Varicoceles: postoperative prevalence-a prospective study with color Doppler US. Radiology. 187(3):711–714CrossRefPubMedGoogle Scholar
  103. 103.
    Rotker K, Sigman M (2016) Recurrent varicocele. Asian J Androl 18(2):229–233CrossRefPubMedPubMedCentralGoogle Scholar
  104. 104.
    Glassberg KI, Badalato GM, Poon SA, Mercado MA, Raimondi PM, Gasalberti A (2011) Evaluation and management of the persistent/recurrent varicocele. Urology. 77(5):1194–1198CrossRefPubMedGoogle Scholar
  105. 105.
    Kwak N, Siegel D (2014) Imaging and interventional therapy for varicoceles. Curr Urol Rep 15(4):399Google Scholar
  106. 106.
    El-Haggar S, Nassef S, Gadalla A, Latif A, Mostafa T (2012) Ultrasonographic parameters of the spermatic veins at the inguinal and scrotal levels in varicocele diagnosis and post-operative repair. Andrologia. 44(3):210–213CrossRefPubMedGoogle Scholar
  107. 107.
    Winkelbauer FW, Ammann ME, Karnel F, Lammer J (1994) Doppler sonography of varicocele: long-term follow-up after venography and transcatheter sclerotherapy. J Ultrasound Med 13(12):953–958CrossRefPubMedGoogle Scholar
  108. 108.
    Palazzo S, Boezio F, Mancini V et al (2002) Significance of scrotal Doppler color ultrasonography in the postoperative control of patients treated with varicocelectomy. Arch Ital Urol Androl 74(4):247–249PubMedGoogle Scholar
  109. 109.
    Hauser R, Yogev L, Greif M et al (1997) Sperm binding and ultrasound changes after operative repair of varicocele: correlation with fecundity. Andrologia. 29(3):145–147CrossRefPubMedGoogle Scholar
  110. 110.
    Zucchi A, Mearini L, Mearini E, Fioretti F, Bini V, Porena M (2006) Varicocele and fertility: relationship between testicular volume and seminal parameters before and after treatment. J Androl 27(4):548–551CrossRefPubMedGoogle Scholar
  111. 111.
    Trombetta C, Salisci E, Deriu M et al (1993) Echo-flowmetric control 6 years after percutaneous treatment of varicocele. Arch Ital Urol Androl 65(4):363–367PubMedGoogle Scholar
  112. 112.
    Haller J, Gritzmann N, Czembirek H et al (1986) Pulsed duplex sonographic follow-up of varicoceles following sclerotherapy. Rofo. 145(5):547–550CrossRefPubMedGoogle Scholar
  113. 113.
    Hamm B, Sorensen R, Berger T (1986) Non-invasive imaging procedures in the diagnosis and control of therapy of varicoceles. 2. Importance of thermography and sonography for therapy control following sclerotherapy of varicoceles. Rofo. 144(6):665–669CrossRefPubMedGoogle Scholar
  114. 114.
    Mastrojeni C, Pagano G, Scalisi M, Leonello G, Manfré A, Versaci A (2001) Idiopathic varicocele. Diagnosis and follow-up with CW-Doppler and echo-color-Doppler: our experience. G Chir. 22(1-2):41–44Google Scholar
  115. 115.
    Cil AS, Bozkurt M, Bozkurt DK, Gok M (2015) Investigating the relationship between persistent reflux flow on the first postoperative day and recurrent varicocele in varicocelectomy patients. J Clin Med Res 7(1):29–32CrossRefPubMedGoogle Scholar
  116. 116.
    El-Saeity NS, Sidhu PS (2006) “Scrotal varicocele, exclude a renal tumour”. Is this evidence based? Clin Radiol 61(7):593–599CrossRefPubMedGoogle Scholar
  117. 117.
    Spittel JA Jr, DeWeerd JH, Shick RM (1959) Acute varicocele: a vascular clue to renal tumor. Proc Staff Meet Mayo Clin 34(5):134–137PubMedGoogle Scholar
  118. 118.
    Gibbons RP, Monte JE, Correa RJ Jr, Mason JT (1976) Manifestations of renal cell carcinoma. Urology. 8(3):201–206CrossRefPubMedGoogle Scholar
  119. 119.
    Skinner DG, Colvin RB, Vermillion CD, Pfister RC, Leadbetter WF (1971) Diagnosis and management of renal cell carcinoma. A clinical and pathologic study of 309 cases. Cancer. 28(5):1165–1177CrossRefPubMedGoogle Scholar
  120. 120.
    El Abiad Y, Qarro A (2016) Acute varicocele revealing renal cancer. N Engl J Med 374(21):2075CrossRefPubMedGoogle Scholar
  121. 121.
    Bate J (1927) Symptomatic varicocele. J Urol 18(6):649–662CrossRefGoogle Scholar
  122. 122.
    Ding GX, Song NH, Feng CC et al (2012) Is there an association between advanced stage of renal cell carcinoma and paraneoplastic syndrome? Med Princ Pract 21(4):370–374CrossRefPubMedGoogle Scholar
  123. 123.
    Ates N, Yuksel M, Ylmaz S, Habibi M, Ipekci T (2016) Retroperitoneal paraganglioma presenting as right-sided varicocele: case report. Ann Saudi Med 36(2):148–151CrossRefPubMedPubMedCentralGoogle Scholar
  124. 124.
    Arrabal-Polo MA, Merino-Salas S (2013) Acute left varicocele in an adult. CMAJ. 185(4):323CrossRefPubMedPubMedCentralGoogle Scholar
  125. 125.
    Chandramohan S, Chakravertry S (2007) Re: “Scrotal varicocoele, exclude a renal tumour”. Is this evidence based? Clin Radiol 62(2):192–193CrossRefPubMedGoogle Scholar
  126. 126.
    Espinosa Bravo R, Lemourt Oliva M, Pérez Monzón AF et al (2003) Carcinoma de células renales y varicocele izquierdo de forma simultánea. Arch Esp Urol 56(5):533–535PubMedGoogle Scholar
  127. 127.
    Robson J, Wolstenhulme S, Knapp P (2012) Is there a co-association between renal or retroperitoneal tumours and scrotal varicoceles? A systematic review. Ultrasound. 20(4):182–191CrossRefGoogle Scholar
  128. 128.
    Oster J (1971) Varicocele in children and adolescents: an investigation of the incidence among Danish school children. Scand J Urol Nephrol 5(1):27–32CrossRefPubMedGoogle Scholar
  129. 129.
    Akbay E, Cayan S, Doruk E, Duce MN, Bozlu M (2000) The prevalence of varicocele and varicocele-related testicular atrophy in Turkish children and adolescents. BJU Int 86(4):490–493CrossRefPubMedGoogle Scholar
  130. 130.
    Erginel B, Vural S, Akin M et al (2014) Wilms’ tumor: a 24-year retrospective study from a single center. Pediatr Hematol Oncol 31(5):409–414CrossRefPubMedGoogle Scholar
  131. 131.
    Pavan N, Bucci S, Mazzon G, Bertolotto M, Trombetta C, Liguori G (2015) It’s not always varicocele: a strange case of Zinner syndrome. Can Urol Assoc J 9(7-8):E535–E538CrossRefPubMedPubMedCentralGoogle Scholar
  132. 132.
    Conzi R, Damasio MB, Bertolotto M et al (2017) Sonography of scrotal wall lesions and correlation with other modalities. J Ultrasound Med 36(10):2149–2163CrossRefPubMedGoogle Scholar
  133. 133.
    Secil M, Bertolotto M, Rocher L et al (2017) Imaging features of paratesticular masses. J Ultrasound Med 36(7):1487–1509CrossRefPubMedGoogle Scholar
  134. 134.
    Yilmaz C, Arslan M, Arslan M (2009) Intrascrotal arteriovenous malformation simulating varicocele. AJR Am J Roentgenol 192(6):W351CrossRefPubMedGoogle Scholar
  135. 135.
    Bhatt S, Jafri SZ, Wasserman N, Dogra VS (2011) Imaging of non-neoplastic intratesticular masses. Diagn Interv Radiol 17(1):52–63PubMedGoogle Scholar

Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  • Simon Freeman
    • 1
    Email author
  • Michele Bertolotto
    • 2
  • Jonathan Richenberg
    • 3
  • Jane Belfield
    • 4
  • Vikram Dogra
    • 5
  • Dean Y. Huang
    • 6
  • Francesco Lotti
    • 7
  • Karolina Markiet
    • 8
  • Olivera Nikolic
    • 9
  • Subramaniyan Ramanathan
    • 10
  • Parvati Ramchandani
    • 11
  • Laurence Rocher
    • 12
    • 13
  • Mustafa Secil
    • 14
  • Paul S. Sidhu
    • 6
  • Katarzyna Skrobisz
    • 8
  • Michal Studniarek
    • 8
  • Athina Tsili
    • 15
  • Ahmet Tuncay Turgut
    • 16
  • Pietro Pavlica
    • 17
  • Lorenzo E. Derchi
    • 18
  • members of the ESUR-SPIWG WG
  1. 1.University Hospitals Plymouth NHS TrustDerriford HospitalPlymouthUK
  2. 2.Department of Radiology, Ospedale di CattinaraUniversity of TriesteTriesteItaly
  3. 3.Brighton and Sussex University Hospitals NHS TrustRoyal Sussex County HospitalBrightonUK
  4. 4.Royal Liverpool University HospitalLiverpoolUK
  5. 5.Department of RadiologyUniversity of RochesterRochesterUSA
  6. 6.King’s College Hospital NHS Foundation Trust, Department of RadiologyKing’s College HospitalLondonUK
  7. 7.Andrology, Female Endocrinology and Gender Incongruence Unit, Department of Experimental and Clinical Biomedical SciencesUniversity of FlorenceFlorenceItaly
  8. 8. Department of RadiologyMedical University of GdanskGdanskPoland
  9. 9.Faculty of Medicine, Center of Radiology, Clinical Center of VojvodinaUniversity of Novi SadNovi SadSerbia
  10. 10.Department of Clinical Imaging, Weill Cornell Medical College, Al-Wakra HospitalHamad Medical CorporationDohaQatar
  11. 11.Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  12. 12.Department of Adult Diagnostic and Interventional RadiologyBicetre University HospitalLe Kremlin BicêtreFrance
  13. 13.Imagerie par Résonance Magnétique Médicale et Multi-Modalités, CNRS UMR8081Service Hospitalier Frédéric JoliotOrsay CedexFrance
  14. 14.Faculty of Medicine, Department of RadiologyDokuz Eylul UniversityIzmirTurkey
  15. 15.Department of Clinical Radiology, Medical SchoolUniversity of IoanninaIoanninaGreece
  16. 16.Department of Radiology, Faculty of MedicineIstinye UniversityIstanbulTurkey
  17. 17.Private Hospital S.M. MaddalenaRovigoItaly
  18. 18.Department of Health Sciences (DISSAL), Emergency RadiologyUniversity of GenoaGenoaItaly

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