Can Bilateral Varicoceles Cause Intermittent Testicular Pain?
Yes, bilateral varicoceles can absolutely cause intermittent testicular pain, affecting 2-10% of men with varicoceles, and this pain typically responds well to treatment with approximately 80% resolution after varicocelectomy in carefully selected candidates. 1
Understanding Varicocele-Related Pain
Varicoceles cause testicular pain through multiple pathophysiologic mechanisms 1:
- Compression of surrounding neural fibers by the dilated venous complex
- Elevated testicular temperature and increased venous pressure
- Hypoxia and oxidative stress in testicular tissue
- Reflux of toxic metabolites from adrenal or renal origin
- Hormonal imbalances affecting testicular function
Pain Characteristics to Assess
The pain from varicoceles typically presents with specific features 1:
- Dull, aching, or throbbing pain in the testicle, scrotum, or groin (most common)
- Rarely acute, sharp, or stabbing in nature
- Intermittent pattern that may worsen with prolonged standing or physical activity
- Bilateral presentation when both sides are affected, though left-sided varicoceles are more common
When to Investigate Further
Right-sided or bilateral varicoceles, especially if the right side is large, warrant abdominal/pelvic imaging to exclude retroperitoneal pathology such as renal masses or venous obstruction. 2 This is a critical red flag that distinguishes benign from potentially serious secondary causes.
Additional concerning features requiring imaging 2:
- New-onset varicoceles in adults
- Large or non-reducible varicoceles
- Sudden change in size or character
Diagnostic Approach
Scrotal ultrasound with Doppler is the imaging modality of choice for confirming varicocele diagnosis and excluding other causes of testicular pain. 3 The ultrasound should demonstrate:
- Dilated veins (>3 mm diameter) in the pampiniform plexus
- Reflux on Valsalva maneuver confirming venous incompetence
- Normal testicular blood flow to exclude torsion or other vascular emergencies 4
Treatment Algorithm
Initial Management
Start with conservative, non-surgical approaches 1:
- Scrotal support with athletic supporters
- NSAIDs for pain control
- Activity modification avoiding prolonged standing
- Observation period of 3-6 months
Surgical Intervention Indications
Proceed with varicocelectomy when: 2, 1
- Conservative management fails after adequate trial period
- Pain significantly impacts quality of life
- Clinical (palpable) varicocele is present - treatment of subclinical varicoceles is not effective 5
- Chronic orchialgia persists despite conservative measures
Expected Outcomes
Varicocelectomy achieves complete pain relief in approximately 80% of carefully selected candidates with clinically palpable varicoceles. 1 For gonadal vein embolization specifically, 87% of patients achieve complete pain relief at 39 months follow-up. 2
Predictors of Surgical Success
Several factors predict better outcomes after varicocelectomy for pain 1, 6:
- Higher varicocele grade (grade 2-3 palpable varicoceles)
- Shorter duration of pain before intervention
- Dull, aching quality rather than sharp, neuropathic pain
- Pain that worsens with standing and improves with recumbency
- Absence of other scrotal pathology
Important Caveats
Do not operate on subclinical (non-palpable) varicoceles identified only by ultrasound, as treatment does not improve pain or fertility outcomes. 5 This is a common pitfall where imaging findings drive unnecessary interventions.
Consider alternative diagnoses if pain persists after varicocelectomy 7:
- Recurrent varicocele requiring repeat imaging
- Post-operative hydrocele development
- Neuralgia from nerve injury during surgery
- Referred pain from other sources
- Nutcracker syndrome causing persistent venous hypertension
The bilateral nature of your patient's varicoceles makes the red flag evaluation particularly important before proceeding with any intervention. 2