Guideline sources The following summarized guidelines for the evaluation and management of varicocele are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2023; 2022), the American Urological Association (AUA/ASRM 2021), and the American Society for Reproductive Medicine (ASRM 2014). 1 2 3 4 5 Guidelines 1. Screening and diagnosis Diagnosis: Diagnose varicocele based primarily on physical examination. Obtain imaging only when physical examination is inconclusive. E Recognize that only clinically palpable varicoceles have been clearly associated with infertility. E 2. Diagnostic investigations Scrotal imaging: As per EAU 2022 guidelines, obtain scrotal ultrasound to detect venous reflux without Valsalva maneuvre in the supine and upright position and to discriminate testicular hypoplasia in pediatric and adolescent patients with varicocele. A https://web.pathway.md/diseases/recgyHDgKR9M3XIXb 1/3 6/29/23, 3:23 AM Varicocele Pathway As per ASRM 2014 guidelines, do not obtain imaging studies for the standard evaluation unless physical examination is inconclusive. D Abdominal imaging: As per EAU 2022 guidelines, obtain standard renal ultrasound to exclude a retroperitonal mass in all prepubertal patients with varicocele and in all isolated right varicoceles. A As per AUA 2021 guidelines, do not obtain routine abdominal imaging for the sole indication of an isolated small or moderate right varicocele. D 3. Surgical interventions Indications for varicocelectomy: As per EAU 2023 guidelines, do not treat varicocele in infertile men who have normal SA and in men with a sub-clinical varicocele. D Show 2 more As per AUA 2021 guidelines, consider performing surgical varicocelectomy in patients attempting to conceive and having palpable varicocele, infertility, and abnormal semen parameters, except for patients with azoospermia. C Show 2 more As per ASRM 2014 guidelines, consider offering varicocele repair with surgical or percutaneous embolization techniques in young male patients not actively trying to conceive and having varicocele and objective evidence of reduced ipsilateral testicular size. E Show 2 more 4. Specific circumstances Pediatric and adolescent patients (evaluation): Examine varicocele in the standing position and classify into three grades: Situation Guidance Small size, palpable only at Valsalva maneuvre Grade I Medium size, palpable without Valsalva maneuvre Grade II Large size, visible at distance. B Grade III Show 2 more Pediatric and adolescent patients, management: As per EAU 2023 guidelines, offer varicocele repair in adolescent patients with ipsilateral reduction in testicular volume and evidence of progressive testicular dysfunction. B As per EAU 2022 guidelines, offer surgery in patients with varicocele associated with any of the following: https://web.pathway.md/diseases/recgyHDgKR9M3XIXb 2/3 6/29/23, 3:23 AM Varicocele Pathway a persistent small testis (size difference of > 2 mL or 20%) additional testicular condition affecting fertility (cryptorchidism, history of torsion, trauma) pathological sperm quality (in older adolescent patients) symptomatic varicocele. B Show 2 more As per ASRM 2014 guidelines, consider offering varicocele repair with surgical or percutaneous embolization techniques in adolescent patients with varicocele and objective evidence of reduced ipsilateral testicular size. E Clinical findings Symptoms Past medical history Groin pain Kidney cancer Scrotal pain Portal hypertension Retroperitoneal fibrosis Genitourinary exam Retroperitoneal tumors Wilms tumor Scrotal "bag-of-worms" appearance Lab findings Scrotal swelling Asthenozoospermia Azoospermia Oligozoospermia Teratozoospermia References 1. Practice Committee of the American Society for Reproductive Medicine, Society for Male Reproduction and Urology. Report on varicocele and infertility: a committee opinion. Fertil Steril. 2014 Dec;102 6 1556 60. Open 2. Lisette A 't Hoen, Guy Bogaert, Christian Radmayr et al. EAU guidelines on Paediatric Urology. EAU. 2022 Mar. Open 3. A. Salonia, C. Bettocchi, J. Carvalho et al. EAU Guidelines on Sexual and Reproductive Health. EAU. 2023. Open 4. Peter N Schlegel, Mark Sigman, Barbara Collura et al. Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline Part I. J Urol. 2021 Jan;205 1 36 43. Open 5. Peter N Schlegel, Mark Sigman, Barbara Collura et al. Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline PART II. J Urol. 2021 Jan;205 1 44 51. Open https://web.pathway.md/diseases/recgyHDgKR9M3XIXb 3/3