Orchialgia and the chronic pelvic pain syndrome

Sensibility, Sensation, and Nerve Regeneration after Reconstructive Genital Surgery: Evolving Concepts in Neurobiology

BACKGROUND

Sensory recovery following phalloplasty and vaginoplasty for gender dysphoria is essential to the overall success of gender-confirming surgery. Anecdotal evidence suggests that superior reinnervation results are seen in genitoplasty compared to other peripheral nerve repair scenarios. Despite these observed differences, the quality of available literature is poor.

METHODS

The authors reviewed the body of English language literature regarding sensory outcomes following genitoplasty for gender confirmation.

RESULTS

The available body of literature discussing the basic science and clinical science aspects of sensory recovery following gender-confirming genitoplasty is small. Available data show that sensory recovery following vaginoplasty produces high rates of reported orgasmic ability, largely through the neoclitoris, and a neovagina with vibratory and pressure sensation similar to that of the native vagina. Phalloplasty sensory outcomes are variable, with the largest series reporting return of sensation in the neophallus that is slightly less than what is measured in control men. Erogenous sensation, including the ability to orgasm, is present in nearly all patients after several months.

CONCLUSIONS

Existing series indicate that genitoplasty patients experience faster and more complete recovery than any other peripheral nerve regeneration scenarios. However, there are many potential confounding factors in assessment and reporting, and more consistent and reproducible measure endpoints measures are needed. Further research is needed to better understand both the basic science and clinical science of peripheral nerve regeneration in genitoplasty, which may change fundamental aspects of current paradigms of peripheral nerve regeneration.

Management of Chronic Orchialgia: Challenges and Solutions - The Current Standard of Care

INTRODUCTION

Chronic scrotal content pain (CSP) or chronic orchialgia can be debilitating for patients and difficult to treat. There is a paucity of structured treatment algorithms to approach this difficult condition.

METHODS

A review of the literature was performed. Conservative treatment options are presented and then targeted surgical interventions that the urologist may perform are then presented in a structured algorithm format. Many of these patients may obtain a significant reduction in pain with some of these treatments.

RESULTS

This review presents the pathophysiology, a new assessment tool, and various treatment options available for CSP patients, such as targeted spermatic cord blocks, targeted and standard microsurgical denervation of the spermatic cord (77-100% success rates), ultrasound-guided peri-spermatic cord and ilioinguinal cryoablation (59-75% success rates), scrotox (botox) (56-72% success rates), targeted ilioinguinal and iliohypogastric peripheral nerve stimulation (72% success rate), radical orchiectomy (20-75% success rate), targeted robotic-assisted intra-abdominal denervation (71% success rate) and vasectomy reversal (69-100% success rates).

CONCLUSION

A structured and evidence-based approach to help urologists manage patients with chronic orchialgia or scrotal content pain is presented.

Microsurgical subinguinal cremaster muscle release for chronic orchialgia secondary to hyperactive cremaster muscle reflex in adults

A careful history and evaluation of men with chronic orchialgia elucidates the aetiology in some men to be a hyperactive cremaster muscle reflex with testicular retraction as the cause. The objective is to evaluate outcomes in men who underwent microsurgical subinguinal cremaster muscle release (MSCMR) with a retrospective chart review between September 2011 and April 2019. Nineteen men with hyperactive cremaster muscle reflex in 25 spermatic cord units underwent MSCMR, six bilateral and thirteen unilateral. Candidacy for MSCMR included answering yes to the question: “at times of testicular pain, does the testicle retract up in the groin to the extent that you have to milk it back down to the scrotum?”, normal digital rectal examinations, negative urinalyses, negative scrotal Doppler ultrasounds, vigorous retraction of testis with Valsalva on examination and pain without an anatomic or pathologically identifiable aetiology except testicular retraction. Of the men who underwent MSCMR, 100% (25/25) of spermatic cord units had resolution of testicular retraction and 92% (23/25) of spermatic cord units had complete resolution of orchialgia. There was one complication, a small scrotal hematoma which resolved. MSCMR is an effective option for men with orchialgia secondary to testicular retraction due to a hyperactive cremaster muscle reflex.

Terazosin or baclofen in young men with chronic orchialgia: A cohort study of 499 patients

PURPOSE

We aimed to investigate the comparative efficacy of terazosin and baclofen in young men with chronic orchialgia using National Institutes of Health Chronic Prostatitis Symptom Index measurement.

PATIENTS AND METHODS

Of 499 young men with chronic orchialgia, 255 received a daily 2 mg terazosin at bedtime and 244 received 10 mg baclofen during a period of 3 months. A daily 10-min hot-tub hip-bath rest was administered for all patients. Moreover, all patients with grade 3 and 18 patients with grade 2 varicocele underwent varicocelectomy. The National Institutes of Health Chronic Prostatitis Symptom Index score was assessed at baseline and 3 months later.

RESULTS

Both terazosin and baclofen groups experienced a significant reduction in mean National Institutes of Health Chronic Prostatitis Symptom Index score (24.78 and 24.81 at baseline to 19.68 and 19.60 after the treatment for terazosin and baclofen groups, respectively). However, there was no significant difference between the groups with regard to post-treatment National Institutes of Health Chronic Prostatitis Symptom Index score after adjustment for the pre-treatment score (p = 0.987). A total of 85 patients (33.4%) in terazosin group and 74 patients (30.3%) in baclofen group underwent varicocelectomy. Addition of the varicocelectomy to the treatment as a multimodal approach had no further improvement in the National Institutes of Health Chronic Prostatitis Symptom Index score.

CONCLUSION

Although a significant reduction was observed in mean National Institutes of Health Chronic Prostatitis Symptom Index score for both terazosin and baclofen groups, there was no significant difference between the treatments. Moreover, addition of varicocelectomy to terazosin or baclofen could not significantly decrease National Institutes of Health Chronic Prostatitis Symptom Index score; thus, varicocelectomy may not be appropriate for men who have some success with medical management. Further randomized studies are warranted.

Relationship between chronic testicular pain and mental health diagnoses

Background

Chronic testicular pain (orchialgia) has been defined as intermittent or constant unilateral or bilateral testicular pain that lasts 3 months or longer, significantly interfering with daily activities, and prompting the patient to seek medical attention. In many instances, the etiology of the pain is not identified. The contribution of psychological factors is unclear. The purpose of this study was to identify the categories of mental health (MH) diagnoses that are most frequently associated with orchialgia and determine if a correlation exists between MH diagnoses and orchialgia.

Methods

A retrospective review was performed to identify all adult patients within the San Antonio Military Health System with a new diagnosis of orchialgia from January 2005 to April 2015. Patients with acute pathology or recent inguinal/scrotal surgery were excluded. A comparative cohort of all men presenting with hydroceles within the same timeframe was obtained. The presence of coexisting MH diagnoses in both cohorts was then determined.

Results

Four hundred and forty-four men met the inclusion criteria for orchialgia, with 133 men presenting with hydroceles. The incidence of orchialgia increased significantly over the study period (P=0.001). MH diagnoses in the study population did trend upward over the years, but not significantly (P=0.063). MH diagnoses were not significantly higher in the cases compared to the controls (21.6% vs. 18.8%, P=0.479). The prevalence of anxiety was twice as high in the cases (9% vs. 4.5%), though not significantly (P=0.075). The prevalence of all MH diagnoses was significantly higher than in the general US population based on National Institute of Mental Health statistics.

Conclusions

The incidence of orchialgia rose significantly over time, but it was not significantly associated with MH diagnoses. These results may also be skewed by the overall higher percentage of MH diagnoses in the study population than in the general population.

Response to duloxetine and gabapentin combination of a patient who has chronical orchialgia with bilateral tubular ectasia of rete testis and multiple epididymal cysts

Tubular ectasia of rete testis (TERT) is a rarely seen benign condition of testis which can cause chronic orchalgia. TERT appears as an anechoic lesion in ultrasonography. However magnetic resonance imaging is a more sophisticated diagnostic tool. TERT is commonly associated with epididymal cysts. Generally a conservative treatment approach is preferred. In some cases surgery is required. In our case, 54-year-old male patient had bilateral TERT associated with bilateral multiple epididymal cysts. He had chronic testicular pain which did not respond to first- line conservative treatments. After use of duloxetine (60 mg PO) plus gabapentine (400 mg PO) combination as a second-line conservative treatment, the patient dramatically responded to this treatment. The patients who have chronic testicular pain caused by bilateral TERT and multiple epididymal cysts may be treated with combination of duloxetine (60 mg PO) plus gabapentine (400 mg PO) combination.

Does transcutaneous electrical nerve stimulation reduce pain and improve quality of life in patients with idiopathic chronic orchialgia? A randomized controlled trial

Background

Chronic orchialgia is defined as testicular pain, which may be either unilateral or bilateral, lasting for more than 3 months. It disturbs a patient’s daily activities and quality of life (QoL), inciting the patient to search for treatments to alleviate the pain. It is estimated that 25% of chronic orchialgia cases are idiopathic.

Purpose

The purpose of this study was to investigate how effective transcutaneous electrical nerve stimulation (TENS) is in pain reduction and how it consequently affects the QoL in patients with idiopathic chronic orchialgia (ICO).

Patients and methods

Seventy-one patients were randomly assigned to group A (study group), which included 36 patients who received TENS and analgesia, and group B (control group), which included 35 patients who received analgesia only. The outcome measures were the participants’ demographic data and results of the visual analog scale (VAS) and QoL questionnaire. These outcomes were measured before and after 4 weeks of treatment and at 2-month follow-up.

Results

The results showed that compared to pretreatment, there was a significant reduction in pain postintervention and at 2-month follow-up in group A (P<0.0001 and <0.001, respectively; F=7.1) as well as a significant improvement in QoL at these time points (P<0.0001 and <0.0001, respectively). There were no significant differences in the VAS score and QoL in group B at different time points of evaluation.

Conclusion

The findings indicate that TENS is effective in reducing pain and improving patients’ QoL in cases of ICO. TENS is an easy-to-use, effective, noninvasive, and simple method for ICO-associated pain control and QoL improvement.

Psychological perspectives in the patient with chronic orchialgia

Chronic orchialgia is a challenging problem to both the practitioner and unhappy patient and may be a poorly understood manifestation of a potential variety of different discrete causes. Treatment options can be wide ranging and include conservative measures, medical therapy, in office treatments and surgical procedures. Research has primarily focused on these more concrete treatment options with little focus on the either co-morbid or causative psychological issues. By at least considering the potential psychological co-morbidities and stressors that may be associated with chronic orchialgia, physicians can better utilize a multi-modal approach to this vexing problem.

Extirpative surgery for chronic orchialgia: is there a role?

Chronic orchialgia is a difficult and frustrating condition for both the patient and clinician. Determining appropriate course of therapy should require extensive conservative measures and consideration of alternative surgical options prior to concluding an orchiectomy is warranted. This manuscript aims to provide the clinician with the information currently available to determine if the anticipated success rate is warranted to consider extirpative surgery for idiopathic chronic orchialgia.

Medical management of chronic orchialgia

Chronic idiopathic orchialgia is a urologic disease process that is as frustrating as it is common. While no consensus exists on management for otherwise-unexplained testicular pain, most providers would agree that once other treatable organic causes are ruled out, initial management should be symptom focused, and should be medical rather than surgical. This chapter presents a review of the evidence available for a variety of pharmacotherapies commonly employed in the treatment of idiopathic chronic orchialgia.

Genital pain: algorithm for management

Chronic testicular pain although becoming very common in our patient population poses a challenge to the physician, the patient and his family. The pathogenesis of chronic orchialgia (CO) is not well understood. The objective of this paper is to review the current literature on chronic testicular pain and its management and to propose an algorithm for its treatment. Abstracts, original papers and review articles were reviewed during a literature search using words such as testicular pain, CO, and microsurgical anatomy of spermatic cord. Chronic scrotal content pain (CSP) is a difficult condition to treat and could be idiopathic or secondary. Conservative therapy is the first line of treatment attempted to allow the patient to return to his routine activities. When conservative treatment fails, patients can now turn toward surgical options such as microsurgical denervation of the spermatic cord (MDSC) which has a success rate published in the 60-85% range and/or minimally invasive therapies such as microcryoablation of the spermatic cord, Botox or Amniofix injection. There is an increase in referrals for CO. The true pathogenesis is still unclear and the road to complete recovery is unsure for certain patients. This paper proposes an algorithm for the management of patients suffering with CO.

What Can We Do for Chronic Scrotal Content Pain?

Chronic scrotal content pain remains one of the more challenging urological problems to manage. This is a frustrating disorder to diagnose and effectively treat for both the patient and clinician, as no universally accepted treatment guidelines exist. Many patients with this condition end up seeing physicians across many disciplines, further frustrating them. The pathogenesis is not clearly understood, and the treatment ultimately depends on the etiology of the problem. This article reviews the current understanding of chronic scrotal content pain, focusing on the diagnostic work-up and treatment options.

Intermittent Testicular Torsion in Adults: An Overlooked Clinical Condition

OBJECTIVES

The aim of this study was to describe the management protocol for intermittent testicular torsion (ITT) in adults and report the outcome of this clinical condition, which is commonly overlooked in adults.

SUBJECTS AND METHODS

Sixty-three patients were included in the study. The inclusion criterion was the presence of sudden intermittent testicular pain over a duration of 3 months. All the patients underwent clinical examination, urine analysis, culture, and scrotal ultrasound with Doppler. The testicle was in an abnormal or in transverse lie and/or could easily be twisted. Scrotal support and analgesia were given for 1 month, then patients were offered orchidopexy or conservative treatment. Nineteen patients chose orchidopexy while 44 chose conservative treatment. Follow-up ranged from 3 months to 2 years. The improvement was assessed using a visual analog pain score. The outcome of the treatment was compared between the surgical and conservative groups using a χ2 test.

RESULTS

The median age of the patients was 28 years (range: 17-50). Of the 19 patients who underwent orchidopexy, the pain resolved or visual analog pain scores improved (median 1/10) in 18 (94.7%) cases. On the other hand, 21 of the 44 (47.7%) cases that chose the conservative approach claimed their pain resolved or improved (visual analog pain scores: median 3/10) with a median of 13 months of follow-up.

CONCLUSION

In this study, scrotal orchidopexy proved to be superior to conservative measures in cases of ITT in adults.

An overview of the management of post-vasectomy pain syndrome

Post-vasectomy pain syndrome remains one of the more challenging urological problems to manage. This can be a frustrating process for both the patient and clinician as there is no well-recognized diagnostic regimen or reliable effective treatment. Many of these patients will end up seeing physicians across many disciplines, further frustrating them. The etiology of post-vasectomy pain syndrome is not clearly delineated. Postulations include damage to the scrotal and spermatic cord nerve structures via inflammatory effects of the immune system, back pressure effects in the obstructed vas and epididymis, vascular stasis, nerve impingement, or perineural fibrosis. Post-vasectomy pain syndrome is defined as at least 3 months of chronic or intermittent scrotal content pain. This article reviews the current understanding of post-vasectomy pain syndrome, theories behind its pathophysiology, evaluation pathways, and treatment options.

Prevalence of Relative Deficiencies in Testosterone and Vitamin B12 Among Patients Referred for Chronic Orchialgia: Implications for Management

Chronic testicular pain (CTP) is a complex pain syndrome that is widely variable in presentation and etiology. Many cases of CTP are thought to be associated with neuropathy and recent data suggest an inflammation-mediated process is more common among patients with CTP. Deficiencies in vitamin B12 and testosterone are common in chronic pain syndromes may play a role in CTP. A retrospective review of men treated for CTP by a single provider over a 2-year period was performed. Patients with serum screening of testosterone and B12 were selected. Patients with total testosterone below 300 ng/dl, free testosterone below 46 pg/ml, or B12 below 400 pg/ml were deemed deficient and offered repletion. Efficacy of treatment was measured based on patient report with a minimum follow-up of either 3 months or resolution of pain symptoms. One hundred and fifty-four (154) men with CTP were identified, with 125 assessed for testosterone and B12 levels. Of these, 95 patients (76%) were deemed deficient. Fifty-six (56) patients elected to receive B12/testosterone replacement. In patients with sufficient follow-up, 24 patients (65%) reported significant improvement of symptoms, 6 patients (16%) reported some improvement, and 7 patients (19%) reported no improvement. The prevalence of testosterone and B12 deficiencies in this study is much higher than that reported for the general population. In addition, when chemical deficiencies were corrected, greater than 80% of patients with sufficient follow-up reported some improvement in pain. This suggests that screening of B12 and testosterone should be incorporated into the assessment of patients with CTP.

Chronic orchialgia: Review of treatments old and new

Introduction:

Chronic orchialgia is historically and currently a challenging disease to treat. It is a diagnostic and therapeutic challenge for physicians. Conservative therapy has served as the first line of treatment. For those who fail conservative therapy, surgical intervention may be required. We aim to provide a review of currently available surgical options and novel surgical treatment options.

Methods:

A review of current literature was performed using PubMed. Literature discussing treatment options for chronic orchialgia were identified. The following search terms were used to identify literature that was relevant to this review: Chronic orchialgia, testicular pain, scrotal content pain, and microsurgical denervation of the spermatic cord (MDSC).

Results:

The incidence of chronic orchialgia has been increasing over time. In the USA, it affects up to 100,000 men per year due to varying etiologies. The etiology of chronic orchialgia can be a confounding problem. Conservative therapy should be viewed as the first line therapy. Studies have reported poor success rates. Current surgical options for those who fail conservative options include varicocelectomy, MDSC, epididymectomy, and orchiectomy. Novel treatment options include microcryoablation of the peri-spermatic cord, botox injection, and amniofix injection.

Conclusion:

Chronic orchialgia has been and will continue to be a challenging disease to treat due to its multiple etiologies and variable treatment outcomes. Further studies are needed to better understand the problem. Treatment options for patients with chronic orchialgia are improving. Additional studies are warranted to better understand the long-term durability of this treatment options.

Scrotal pain: evaluation and management

Scrotal pain is a common complaint in a urological practice. Its diagnosis can prove challenging in both acute and chronic forms and requires a thorough and complete history and physical examination. This article discusses the evaluation and management of several entities of scrotal pain, including testicular torsion, epididymitis, postvasectomy pain, varicocele, and chronic orchialgia.

Clinical phenotyping of urologic pain patients

PURPOSE OF REVIEW

Urologic pain conditions such as chronic prostatitis/chronic pelvic pain syndrome, interstitial cystitis/bladder pain syndrome and chronic orchialgia are common, yet diagnosis and treatment are challenging. Current therapies often fail to show efficacy in randomized controlled studies. Lack of efficacy may be due to multifactorial causes and heterogeneity of patient presentation. Efforts have been made to map different phenotypes in patients with urologic pain conditions to tailor more effective therapies. This review will look at current literature on phenotype classification in urologic pain patients and their use in providing effective therapy.

RECENT FINDINGS

There has been validation of the 'UPOINT' system (urinary symptoms, psychosocial dysfunction, organ specific findings, infection, neurologic/systemic and tenderness of muscle) to better categorize male chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis/bladder pain syndrome. Refinement of domain systems and recent cluster analysis has suggested possible central processes involved in urologic pain conditions similar to systemic pain syndromes such as fibromyalgia, chronic fatigue and irritable bowel syndrome.

SUMMARY

Domain characterization of urologic pain conditions via phenotype mapping can be used to better understand causes of chronic pain and hopefully provide more effective, targeted and multimodal therapy.