Follow-Up Imaging for Bilateral Varicoceles with Intermittent Pain
No routine follow-up imaging is needed for bilateral varicoceles causing intermittent pain once the initial diagnosis is confirmed by duplex Doppler ultrasound. 1
Initial Diagnostic Approach
The diagnosis of bilateral varicoceles requires confirmation with scrotal duplex Doppler ultrasound, which serves as both the diagnostic and baseline imaging study. 1 This initial ultrasound should include:
- Grayscale imaging to assess testicular size, texture, and homogeneity 1
- Color and power Doppler to evaluate venous reflux and measure vein diameter during Valsalva maneuver 1, 2
- Bilateral evaluation of both the scrotal contents and inguinal regions 1
The ultrasound confirms varicocele when dilated veins measure >2 mm in clinical varicoceles or 1.5-2 mm in subclinical cases, with increased diameter during Valsalva. 2, 3
When Follow-Up Imaging IS Indicated
Follow-up scrotal ultrasound is specifically indicated only in these clinical scenarios:
- Adolescents with testicular size discrepancy - Repeat ultrasound at 6-month intervals to document persistent testicular volume difference >2 mL or >20%, which would indicate need for surgical intervention 4, 2
- Post-varicocelectomy - Ultrasound to confirm procedural success and resolution of venous reflux 2
- Change in clinical presentation - New acute severe pain, palpable mass, or testicular enlargement that suggests alternative pathology 1
- Fertility evaluation - If the patient develops infertility concerns, repeat imaging may be warranted to reassess varicocele grade and testicular parameters 4, 2
When Follow-Up Imaging is NOT Indicated
Routine surveillance imaging for stable bilateral varicoceles with intermittent pain alone is not recommended. 1, 2 The key reasons include:
- Intermittent pain does not require serial imaging to monitor varicocele progression 1
- Physical examination is sufficient for monitoring stable varicoceles in adults 2, 5
- Treatment decisions are based on clinical symptoms, fertility parameters, and testicular size—not imaging changes over time 4, 2
Important Clinical Caveats
Bilateral varicoceles are far more common than traditionally recognized. Studies using venography and ultrasound demonstrate that 80% of varicoceles are actually bilateral, though only the left side may be clinically palpable. 6 This has important implications:
- The initial ultrasound should always evaluate both sides, even if only unilateral varicocele is palpable 7, 6
- Routine ultrasound screening to detect subclinical (non-palpable) varicoceles is discouraged, as treatment of subclinical varicoceles does not improve fertility outcomes 4, 2
Pain alone is not an indication for repeated imaging. 1 Management of intermittent pain should focus on:
- Conservative measures (scrotal support, NSAIDs)
- Consideration for varicocelectomy if pain significantly impacts quality of life
- Evaluation for alternative causes if pain pattern changes or becomes acute 1
The ACR Appropriateness Criteria emphasize that ultrasound is "usually appropriate" for initial evaluation of scrotal pain, but do not recommend routine surveillance imaging for chronic stable conditions. 1