Imaging

Varicocele

Preliminary Diagnosis: Varicocele

I. What imaging technique is first-line for this diagnosis

  • Gray scale with color Doppler sonographic evaluation. Resting and Valsalva color Doppler sonographic images of the epididymis should be obtained.

II. Describe the advantages and disadvantages of this technique for diagnosis of varicocele.

Advantages

  • Relatively inexpensive and portable imaging modality that does not use ionizing radiation.

  • It is easier to identify prominent color flow within vessels with Valsalva secondary to retrograde flow.

  • May visualize dilated serpiginous veins behind the superior pole of the testis on color Doppler ultrasound.

  • May be able to identify small varicoceles which may be only identified on dynamic Valsalva.

  • May be able to identify a mass obstructing the IVC or renal vein.

Disadvantages

  • Limited in evaluating obese patients, where dilated veins of the pampiniform plexus and deep structures are not identified due to overlying soft tissue

  • Operator-dependent

III. What are the contraindications for the first-line imaging technique?

  • No significant contraindication to ultrasound imaging exists.

IV. What alternative imaging techniques are available?

  • Catheter venography

V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of varicocele.

Catheter venography

Advantages

  • May aid in diagnosis

  • Can detail the anatomy of the varicocele

Disadvantages

  • Invasive procedure that includes all the risks associated with an invasive procedure, i.e., bleeding, pain, infection, and damage to nerves, vessels, and visceral organs.

  • May not be able to detail venous obstruction/invasion of the left renal vein by a renal mass, nodes, or adrenal tumor, all of which would be better visualized via ultrasound or cross sectional imaging.

VI. What are the contraindications for the alternative imaging techniques?

Catheter venography

  • May be contraindicated in hypocoagulable patients and those with renal failure, although minimal intravenous contrast is utilized.

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