Abstract
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.
Abbreviations
- AGREE:
-
Appraisal of Guidelines for Research and Evaluation
- AVMs:
-
Arteriovenous malformations
- ESUR:
-
European Society of Urogenital Radiology
- GRADE:
-
Grading of Recommendations Assessment, Development and Evaluation
- H:
-
Height
- L:
-
Length
- OCEBM:
-
Oxford Centre for Evidence Based Medicine
- PICO:
-
Patient Problem (or Population), Intervention, Comparison or Control, Outcome
- Sec:
-
Seconds
- SPIWG:
-
Scrotal and Penile Imaging Working Group
- V:
-
Volume
- W:
-
Width
- WG:
-
Guideline writing group
References
Paick S, Choi WS (2019) Varicocele and testicular pain: a review. World J Mens Health 37(1):4–11
Dubin L, Amelar RD (1970) Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Fertil Steril 21(8):606–609
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):1556–1560
Khera M, Lipshultz LI (2008) Evolving approach to the varicocele. Urol Clin North Am 35(2):183–189
Zini A, Dohle G (2011) Are varicoceles associated with increased deoxyribonucleic acid fragmentation? Fertil Steril 96(6):1283–1287
Jungwirth A, Giwercman A, Tournaye H et al (2012) European Association of Urology guidelines on male infertility: the 2012 update. Eur Urol 62(2):324–332
Agarwal A, Deepinder F, Cocuzza M et al (2007) Efficacy of varicocelectomy in improving semen parameters: new meta-analytical approach. Urology. 70(3):532–538
Brouwers MC, Kho ME, Browman GP et al (2010) AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 182(18):E839–E842
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):2845–2855
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):395–400
Medicine OCfE-B. The Oxford 2011 Levels of Evidence 2011 Available from: https://www.cebm.net/2016/05/ocebm-levels-of-evidence/. Accessed April 2019
Plus EE. GRADE: Grading of Recommendations Assessment, Development and Evaluation (A, B, C, D): John Wiley & Sons, Inc; 2018. Available from: http://www.essentialevidenceplus.com/product/concept_infomastery.cfm. Accessed April 2019
Dalkey N, Helmer O (1963) An experimental application of the DELPHI method to the use of experts. Manag Sci 9(3):458–467
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: https://uroweb.org/wp-content/uploads/EAU-Guidelines-on-Male-Infertility-2018-large-text.pdf. Accessed April 2019
Saypol DC (1981) Varicocele. J Androl 2(2):61–71
Alsaikhan B, Alrabeeah K, Delouya G, Zini A (2016) Epidemiology of varicocele. Asian J Androl 18(2):179–181
Dubin L, Amelar RD (1971) Etiologic factors in 1294 consecutive cases of male infertility. Fertil Steril 22(8):469–474
Kibar Y, Seckin B, Erduran D (2002) The effects of subinguinal varicocelectomy on Kruger morphology and semen parameters. J Urol 168(3):1071–1074
Zini A, Boman JM (2009) Varicocele: red flag or red herring? Semin Reprod Med 27(2):171–178
Liguori G, Trombetta C, Garaffa G et al (2004) Color Doppler ultrasound investigation of varicocele. World J Urol 22(5):378–381
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):461–472
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):841–852
Naughton CK, Nangia AK, Agarwal A (2001) Varicocele and male infertility: Part II: pathophysiology of varicoceles in male infertility. Hum Reprod Update 7(5):473–481
Papanikolaou F, Chow V, Jarvi K, Fong B, Ho M, Zini A (2000) Effect of adult microsurgical varicocelectomy on testicular volume. Urology. 56(1):136–139
Jung A, Schuppe HC (2007) Influence of genital heat stress on semen quality in humans. Andrologia. 39(6):203–215
Evers JH, Collins J, Clarke J (2008) Surgery or embolisation for varicoceles in subfertile men. Cochrane Database Syst Rev 2008(3):CD000479. https://doi.org/10.1002/14651858.CD000479.pub3
Kroese AC, De Lange NM, Collins JA, Evers JL (2013) Varicocele surgery, new evidence. Hum Reprod Update 19(4):317
Kroese ACJ, de Lange NM, Collins J, Evers JL (2012) Surgery or embolization for varicoceles in subfertile men. Cochrane Database Syst Rev (10):CD000479. https://doi.org/10.1002/14651858.CD000479.pub5
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):270–274
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):796–808
Macleod R, Biyani CS, Cartledge J, Eardley I (2015) Varicocele. BMJ Clin Evid 2015
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):703–709
Fertility: assessment and treatment for people with fertility problems. National Institute for Health and Clinical Excellence: Guidance [CG11]. London (UK) 2004. www.nice.org.uk/guidance/cg11. Accessed April 2019
Lotti F, Maggi M (2014) Ultrasound of the male genital tract in relation to male reproductive health. Hum Reprod Update 21(1):56–83
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):50–56
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):430–438
Sarteschi LM, Paoli R, Bianchini M, Menchini Fabris GF (1993) Lo studio del varicocele con eco-color-Doppler. G Ital Ultrasonologia 4(2):43–49
Hoekstra T, Witt MA (1995) The correlation of internal spermatic vein palpability with ultrasonographic diameter and reversal of venous flow. J Urol 153(1):82–84
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):953–956
Cornud F, Belin X, Amar E, Delafontaine D, Helenon O, Moreau JF (1999) Varicocele: strategies in diagnosis and treatment. Eur Radiol 9(3):536–545
Oyen RH (2002) Scrotal ultrasound. Eur Radiol 12(1):19–34
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):199–204
Iosa G, Lazzarini D (2013) Hemodynamic classification of varicoceles in men: our experience. J Ultrasound 16(2):57–63
Patil V, Shetty SC, Das SK (2016) Redefining the criteria for grading varicoceles based on reflux times: a clinicoradiological correlation. Ultrasound Q 32(1):82–85
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):775–779
Gonda RL Jr, Karo JJ, Forte RA, O'Donnell KT (1987) Diagnosis of subclinical varicocele in infertility. AJR Am J Roentgenol 148(1):71–75
Orda R, Sayfan J, Manor H, Witz E, Sofer Y (1987) Diagnosis of varicocele and postoperative evaluation using inguinal ultrasonography. Ann Surg 206(1):99–101
McClure RD, Khoo D, Jarvi K, Hricak H (1991) Subclinical varicocele: the effectiveness of varicocelectomy. J Urol 145(4):789–791
Eskew LA, Watson NE, Wolfman N, Bechtold R, Scharling E, Jarow JP (1993) Ultrasonographic diagnosis of varicoceles. Fertil Steril 60(4):693–697
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):645–650
Jarow JP, Ogle SR, Eskew LA (1996) Seminal improvement following repair of ultrasound detected subclinical varicoceles. J Urol 155(4):1287–1290
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):250–252
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 3:17
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):144–149
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):345–350
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):65–68
Zampieri N, Cervellione RM (2008) Varicocele in adolescents: a 6-year longitudinal and followup observational study. J Urol 180(4):1653–1656
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):1012–1016
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):485–489
Cornud F, Amar E, Hamida K, Thiounn N, Helenon O, Moreau JF (2000) Imaging in male hypofertility and impotence. BJU Int 86:153–163
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):56–64
Kim ED, Lipshultz LI (1996) Role of ultrasound in the assessment of male infertility. J Clin Ultrasound 24(8):437–453
Condorelli R, Calogero AE, La Vignera S (2013) Relationship between testicular volume and conventional or nonconventional sperm parameters. Int J Endocrinol 2013:6
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):136–140
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):319–324
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):529–533
Lambert B (1951) The frequency of mumps and of mumps orchitis and the consequences for sexuality and fertility. Acta Genet Stat Med 2(Suppl. 1:1–166
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):69–73
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):152–157
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 16:47–53
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):455–461
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):1074–1078
Cornud F, Amar E, Hamida K, Helenon O, Moreau JF (2001) Ultrasound findings in male hypofertility and impotence. Eur Radiol 11(11):2126–2136
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):251–256
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):2717–2722
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):316–321
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):1091–1096
Glassberg KI (2014) My indications for treatment of the adolescent varicocele (and why?). Trans Androl Urol 3(4):402–412
Paduch DA, Niedzielski J (1997) Repair versus observation in adolescent varicocele: a prospective study. J Urol 158(3):1128–1132
Poon SA, Gjertson CK, Mercado MA, Raimondi PM, Kozakowski KA, Glassberg KI (2010) Testicular asymmetry and adolescent varicoceles managed expectantly. J Urol 183(2):731–734
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):121–124
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):1897–1902
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 25:71–75
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):1900–1906
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):179–182
Ross JA, Watson JN Jr, Jarow JP (1994) The effect of varicoceles on testicular blood flow in man. Urology. 44(4):535–539
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):389–393
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):38–42
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):903–908
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):191–195
Baigorri BF, Dixon RG (2016) Varicocele: a review. Semin Intervent Radiol 33(3):170–176
(1985) Comparison among different methods for the diagnosis of varicocele. World Health Organisation.. Fertil Steril 43(4):575–582
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):1998–2006
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):322–327
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):1414–1417
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):13–19
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):1001–1003
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):1536–1542
Cervellione RM, Corroppolo M, Bianchi A (2008) Subclinical varicocele in the pediatric age group. J Urol 179(2):717–719
Zampieri N, Dall’Agnola A (2011) Subclinical varicocele and sports: a longitudinal study. Urology. 77(5):1199–1202
Diamond DA (2007) Adolescent varicocele. Curr Opin Urol 17(4):263–267
Cvitanic OA, Cronan JJ, Sigman M, Landau ST (1993) Varicoceles: postoperative prevalence-a prospective study with color Doppler US. Radiology. 187(3):711–714
Rotker K, Sigman M (2016) Recurrent varicocele. Asian J Androl 18(2):229–233
Glassberg KI, Badalato GM, Poon SA, Mercado MA, Raimondi PM, Gasalberti A (2011) Evaluation and management of the persistent/recurrent varicocele. Urology. 77(5):1194–1198
Kwak N, Siegel D (2014) Imaging and interventional therapy for varicoceles. Curr Urol Rep 15(4):399
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):210–213
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):953–958
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):247–249
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):145–147
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):548–551
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):363–367
Haller J, Gritzmann N, Czembirek H et al (1986) Pulsed duplex sonographic follow-up of varicoceles following sclerotherapy. Rofo. 145(5):547–550
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):665–669
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):41–44
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):29–32
El-Saeity NS, Sidhu PS (2006) “Scrotal varicocele, exclude a renal tumour”. Is this evidence based? Clin Radiol 61(7):593–599
Spittel JA Jr, DeWeerd JH, Shick RM (1959) Acute varicocele: a vascular clue to renal tumor. Proc Staff Meet Mayo Clin 34(5):134–137
Gibbons RP, Monte JE, Correa RJ Jr, Mason JT (1976) Manifestations of renal cell carcinoma. Urology. 8(3):201–206
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):1165–1177
El Abiad Y, Qarro A (2016) Acute varicocele revealing renal cancer. N Engl J Med 374(21):2075
Bate J (1927) Symptomatic varicocele. J Urol 18(6):649–662
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):370–374
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):148–151
Arrabal-Polo MA, Merino-Salas S (2013) Acute left varicocele in an adult. CMAJ. 185(4):323
Chandramohan S, Chakravertry S (2007) Re: “Scrotal varicocoele, exclude a renal tumour”. Is this evidence based? Clin Radiol 62(2):192–193
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):533–535
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):182–191
Oster J (1971) Varicocele in children and adolescents: an investigation of the incidence among Danish school children. Scand J Urol Nephrol 5(1):27–32
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):490–493
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):409–414
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–E538
Conzi R, Damasio MB, Bertolotto M et al (2017) Sonography of scrotal wall lesions and correlation with other modalities. J Ultrasound Med 36(10):2149–2163
Secil M, Bertolotto M, Rocher L et al (2017) Imaging features of paratesticular masses. J Ultrasound Med 36(7):1487–1509
Yilmaz C, Arslan M, Arslan M (2009) Intrascrotal arteriovenous malformation simulating varicocele. AJR Am J Roentgenol 192(6):W351
Bhatt S, Jafri SZ, Wasserman N, Dogra VS (2011) Imaging of non-neoplastic intratesticular masses. Diagn Interv Radiol 17(1):52–63
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Freeman, S., Bertolotto, M., Richenberg, J. et al. 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. Eur Radiol 30, 11–25 (2020). https://doi.org/10.1007/s00330-019-06280-y
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DOI: https://doi.org/10.1007/s00330-019-06280-y