The significance of clinical practice guidelines on adult varicocele detection and management

Abstract

Varicoceles are the most common correctable etiology of male factor infertility. However, the detection and management of varicoceles have not been standardized. This has led to decades of debate regarding the effect of varicocele on male infertility and subsequently whether repair leads to an improved fertility status. The current body of evidence investigating the role of varicocele and varicocelectomy is weak and conflicting. The stance taken by the AUA and ASRM suggests that there is insufficient outcomes data to support evidenced-based guidelines, citing evidence used to provide current recommendations are generally of a low quality level. On the other hand, the EAU Guidelines give a level 1a of evidence for management of varicoceles that are clinically palpable, associated with subnormal semen analyses and having otherwise unexplained fertility. Besides aiding with clinical varicocele detection and management, clinical practice opinion statements and guidelines aim to direct and strengthen the infrastructure of future studies. We review the current status of opinion statements and guidelines in varicocele and management detection with focus on their application in practice.

Potential role of imaging in assessing harmful effects on spermatogenesis in adult testes with varicocele

“…A clinical varicocele is found in approximately 15% of all adult males, up to 35% of infertile men and 81% of men presenting with secondary infertility. When classified according to semen analysis parameters, 12% of infertile men with normal semen analyses and 25.4% of those with abnormal results were found to have clinical varicocele[4,5,8,12,14]. This disorder may be present at birth or in young children, but the incidence substantially increases in adolescents coinciding with pubertal development[4,5,14].…”

“…Physical examination represents the gold standard for the diagnosis of clinically significant varicoceles[5,8,12,24]. It is used by clinical urologists and pediatricians, consisting of palpation performed with the patient in the standing position and observation of the scrotum during the Valsalva maneuver.…”

“…A combination of several factors affects spermatogenesis and sperm function, and the relative involvement of these factors is different in each patient[4,7,8,25]. Several pathophysiologic mechanisms resulting in impairment of spermatogenesis in left varicocele have been proposed, including heat stress, notch signaling, cadmium accumulation, insufficiency of the hypothalamo-pituitary-gonadal axis, retrograde flow of adrenal or renal metabolites, possible disruptions of blood-testis barrier, testicular hypoxia and alterations in testicular extracellular fluid dynamics[4,7,8,25]. Interstitial lesions, including the proliferation of Leydig cells, thickening of the tubular basement membrane and blood vessel wall with luminal narrowing, and increased deposition of interstitial collagen fibers may also play an important role in varicocele-related testicular dysfunction[25].…”

“…Current evidence suggests the primary role of reactive oxygen species (ROS) and the resultant oxidative stress (OS) in the pathogenesis of varicocele-associated male infertility[4,7,8,18,25,26]. Excessive ROS has also been associated with sperm DNA fragmentation (SDF), which may mediate the clinical manifestation of poor sperm function and infertility related to varicocele[4,7,8,18,25-27].…”

“…There are numerous surgical and non-surgical techniques for treating clinically significant varicocele, although there is no consensus on which might be considered the treatment of choice[4,5,7,8,11,25,76-78]. Microsurgical varicocelectomy is the most recommended type of therapy and is associated with fewer complications and lower recurrence rates, compared to the other techniques[4,11].…”