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Review |
From the Division of Urology, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada.
| Correspondence to: Dr Keith Jarvi, Murray Koffler Urologic Wellness Centre, Mount Sinai Hospital, 60 Murray St, 6th Floor, Toronto, Ontario, Canada M5T 3L9 (e-mail: Kjarvi{at}mtsinai.on.ca). |
| Received for publication June 27, 2007; accepted for publication November 27, 2007. |
Clinical examination of the scrotum remains the most commonly used
technique to diagnose varicoceles. However, scrotal anatomy (eg, thick
scrotum, scarring, hydrocele) in some men may make physical examination alone
unreliable. In these situations, imaging (eg, ultrasound, Doppler imaging,
venography) may be used to diagnose a varicocele. The dilemma is that there
are no widely accepted or used criteria to diagnose a varicocele based on
imaging. This paper reviews the different imaging techniques used and the
accuracy of each in diagnosing a varicocele.
Varicoceles are detected more frequently in the infertile male population compared with fertile men. The presence of a varicocele has been associated with impaired testicular function, often causing abnormalities in semen parameters (Dubin and Amelar, 1977; Cockett et al, 1979; Marks et al, 1986; World Health Organization, 1992; Su et al, 1995; Vazquez-Levin et al, 1997). Despite these associations, the majority of men with varicoceles are still fertile. And so the question of whether varicocele repair improves male factor fertility, and subsequently pregnancy rates, is one that has been asked and debated. Although many answers have been proposed, to date there is no clear consensus (Marmar and Kim, 1994; Schlesinger et al, 1994; Madgar et al, 1995; Schlegel, 1997; Nieschlag et al, 1998; Evers and Collins, 2003; Prabakaran et al, 2007). Furthermore, the issue of subclinical varicocelectomy has also been much debated, and with very sparse literature, there is also much controversy in the role of repairing subclinical varicoceles (McClure et al, 1991; Dhabuwala et al, 1992; Marsman and Schats, 1994; Jarow et al, 1996). Many have proposed that prospective, randomized controlled trials are required to answer this management question adequately. However, prior to investigating the benefit of treating varicoceles, the initial dilemma that needs to be addressed is a diagnostic one.
Whether or not one believes that treatment of clinical, or for that matter subclinical, varicoceles improves fertility rates, there is no current consensus on how to diagnose such varicoceles. The American Urology Association and the Practice Committee of the American Society of Reproductive Medicine (ASRM) currently recommend that treatment be offered only when varicoceles are palpable (Practice Committee of the ASRM, 2006). However, the issue of interobserver and intraobserver variability when diagnosing varicoceles has been well documented. In 1985, the World Health Organization found that physical examination had a sensitivity of only roughly 50% in detecting varicoceles when compared to venography, with a false-positive rate of 23% (World Health Organization, 1985). A study out of Washington University in 1991 found that physical examination alone detected only 71% of varicoceles evident on venography (Petros et al, 1991).
Aside from the issue of sensitivity, physical examination can often be inconclusive or equivocal—for example, in patients with a history of previous scrotal surgery, concomitant hydroceles, morbid obesity, etc. As such, the ASRM also recommends that imaging studies be employed to evaluate infertile men with varicoceles when physical examination is inconclusive (Practice Committee of the ASRM, 2006). There are a variety of noninvasive diagnostic imaging modalities that have been introduced in an attempt to more accurately diagnose clinically significant varicoceles, ranging from scrotal contact thermography to radionuclide angiography. Among them, color Doppler ultrasound (CDUS) has become the most widely accepted, as well as frequently used, modality for evaluating varicoceles.
CDUS has been found to have better diagnostic accuracy than physical examination in several different studies. Petros et al (1991) found that CDUS was able to detect 93% of varicoceles evident on venography and that 80% of patients with a normal examination but positive CDUS had confirmatory venograms. Another group, from the Netherlands, found that CDUS had a sensitivity of 97% and specificity of 94% when compared to spermatic venography (Trum et al, 1996). However, there is no current consensus on what parameters found on CDUS are to be used to make the diagnosis of a varicocele.
The presence of multiple veins >3.0–3.5 mm with concomitant reversal of flow after Valsalva is the most widely used criteria for diagnosing a varicocele on CDUS (Rifkin et al, 1983; Wolverson et al, 1983; McClure and Hricak, 1986; Hoekstra and Witt, 1995). Indeed, Jarow et al (1996) found that men with spermatic veins >3 mm had significant improvement of semen parameters after varicocelectomy when compared to men with varicoceles <3 mm. However, there are some studies that speculate that varicoceles are any spermatic vein >1 mm, whereas others claim that only veins >5 mm are clinically significant varicoceles (Hamm et al, 1986; Metin et al, 1991; Eskew et al, 1993; Steckel et al, 1993; Pierik et al, 1998). Having said this, the fact that there is no clear-cut standardized size criterion may be not only a result of the lack of proper prospective trials, but a manifestation of a spectrum phenomenon in which there is no clear discrete normal value.
For many clinicians, the presence of reversal of flow with Valsalva on CDUS is also deemed essential to the diagnosis of a varicocele. However, Cvitanic et al (1993) noted that although 91% of postvaricocelectomy patients had no evidence of varicocele on physical examination, 64% of these patients did in fact have reversal of flow on CDUS. They also noted a prevalence of reversal of flow on CDUS in 42% of their healthy, fertile male population. Meacham et al (1994) studied 34 asymptomatic young men with normal semen parameters and found that 15% had varicoceles by physical examination, whereas 35% had reversal of flow on CDUS (Meacham et al, 1994). Kocakoc et al (2002) also found similar results in their study of 56 healthy men, all of whom had normal semen parameters, wherein 62% of men with spermatic veins 3 mm or less in diameter had reversal of flow after Valsalva.
So if the mere presence of venous reflux on CDUS is not always significant, quantification to determine significant and insignificant levels of reversal of flow is necessary before it can be used to guide management of varicoceles. Several investigators from France looked at quantifying reversal of flow associated with varicoceles and found that CDUS was not an adequate imaging modality and that pulsed-mode Doppler ultrasound was required to measure duration of reflux accurately (Cornud et al, 1999). They graded the degree of reflux into 3 different groups; grade 1 (brief) reflux lasts less than 1 second and is considered physiologic; grade 2 (intermediate) reflux lasts 1–2 seconds and decreases during the Valsalva maneuver, then disappears prior to the end of the maneuver; and grade 3 (permanent) reflux lasts more than 2 seconds and has a plateau aspect throughout the Valsalva maneuver. Although it did not correlate with the diameter of the spermatic vein, grade 3 reflux was found to be palpable in 60% of cases, whereas intermediate and brief reflux were never palpable. Cornud et al (1999) also noted that only treatment of subclinical varicoceles with grade 3 reflux resulted in changes similar to those seen after repair of palpable varicoceles.
When investigating the accuracy of physical examination, CDUS, and other diagnostic modalities, spermatic venography is almost invariably used by researchers as the gold standard. Although invasive and time-consuming, venography is considered to be the gold standard because of the belief that it is not susceptible to technical variation and interobserver variability. However, inaccurate placement of the catheter tip, performing venography under high pressure, and anatomic variations have all been shown to lead to false-positive and false-negative results (Nadel et al, 1984; Pryor and Howards, 1987; Wishahi, 1991; Chiou et al, 1997). So even the gold standard, to which we compare all of our diagnostic modalities used to guide the treatment of varicoceles, is not without limitation.
The dilemma of the merits of repairing varicoceles, both clinical and subclinical, is one that has been debated earnestly over the last few decades. Though there is some evidence to suggest that there may be some benefit to this practice, further well-designed studies are required before we form a clear consensus. Before we embark on this journey, however, it seems clear that the diagnostic dilemma is one that must be addressed first and foremost. Chiou et al (1997) proposed the use of a scoring system that improved CDUS sensitivity to 93% and specificity to 85% when compared to physical examination. They proposed incorporating maximal venous diameter, the presence of a venous plexus and the sum of the diameters of veins in the plexus, and the change of flow on Valsalva maneuver.
Clearly, standardization of examination and imaging techniques is needed to decrease, if not eliminate, observer variability. Strict diagnostic criteria for the different imaging modalities must be set in order for us to be able to compare data from different studies and accurately discern which patients may or may not derive benefit from surgical management. If CDUS is to be the initial imaging modality of choice, then we should always report the presence and duration of reflux, during both normal respiration and Valsalva, as well as reporting whether this is recorded from the inguinal canal or scrotum. Measurements should be made supine and standing and the number and size of all veins should be accurately reported. Until we ensure the validity and reliability of our measurement tools, we cannot accurately determine whether and which of our infertile patients would gain benefit from treatment.
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