Chronic testicular pain: an overview

Pulsed Radiofrequency Ablation for Orchialgia-A Literature Review

Pulsed radiofrequency, short bursts of radiofrequency energy, has been used by pain practitioners as a non- or minimally neurodestructive technique, an alternative to radiofrequency heat lesions. The clinical advantages and mechanisms of this treatment remain unclear. To review the current clinical implication of the pulsed radiofrequency technique for male patients with chronic scrotal pain. We systematically searched the English literature available at the EMBASE, MEDLINE/PubMed, Google Scholar, and Cochrane Library from inception to 22 November 2022. Only reports on a pulsed radiofrequency application on male patients with chronic scrotal pain were included. The final analysis yielded six reports on the clinical use of pulsed radiofrequency applications in male patients with chronic scrotal pain: six full publications, three case reports, one case series, one prospective uncontrolled pilot study, and one prospective randomized, controlled clinical trial. The accumulation of these data shows that using pulsed radiofrequency generates an increasing interest in pain physicians, radiologists, and urologists for managing chronic scrotal pain. No side effects related to the pulsed radiofrequency technique were reported to date. Further research on the clinical and biological effects is justified. Large sample sizes and randomized clinical trials are warranted.

Testicular pain and youtube™: are uploaded videos a reliable source to get information?

Several previous studies on YouTube™ on urological field have already been published. The aim of the current study was to evaluate the quality information of YouTube^TM videos on testicular pain. Using Google Trends tool, the frequency of worldwide YouTube^TM and Google Search on testicular pain was examined from 2010 to 2020. The keywords "testicular pain", "testicular ache" and "scrotal pain" were used on the YouTube platform and the first 100 YouTube^TM videos were analyzed for each one. The Patient Education Materials Assessment Tool (PEMAT) for Audiovisual (A/V) Materials, the DISCERN score and Misinformation tool were used to assess video quality. According to YouTube™ Search the mean relative frequency search for "testicular pain" ranged from 10.5 to 30.0%. According to Google^TM Search it ranged from 73.7 to 91.0%, Of all 300 videos, 117 were eligible for the analysis. The median number of views, thumbs-up and thumbs-down was respectively: 47060 (interquartile range [IQR] = 6297.0-144188.0), 289 (IQR = 40-912) and 19 (IQR = 4-53). Of all videos, 68.4% and 31.6% were produced respectively by Medical Doctors and Other. The median PEMAT Actionability and Understandability scores were 66.7% and 66.7%, respectively. The median DISCERN score ranged from 1 to 5, with an overall median score of 3, defined from question 16. The median misinformation score ranged from 2 to 5. In conclusion, an increased interest on testicular pain was recorded on both YouTube^TM and Google search during the last decade. However, according to the quality assessment tools used, YouTube™ users cannot get trustful and exhaustive information on testicular pain. Therefore, authors with/without medical background should improve the quality of information on YouTube™ videos.

Arteriovenous haemangioma of the vas deferens: a case report and literature review

Arteriovenous haemangioma of the vas deferens is an extremely rare entity in clinical practice. To date, there have been no clinical or pathological cases reported in Medline, Embase or other published English literature. Herein, a 50-year-old male who presented with right scrotal pain for 4 years after vasectomy was admitted to our hospital. One painful nodule was palpable in the right scrotum on physical examination. Color Doppler ultrasound merely showed dilation of the epididymis and no additional information concerning the painful nodule in the right scrotum. Moreover, the laboratory test results were all within normal limits. Ibuprofen was administered to the patient for 2 months with a poor effect, and then spermatic cord block significantly relieved his symptoms. This patient underwent resection of the right painful nodule of the vas deferens under medical advice. Postoperative pathological examinations showed arteriovenous haemangioma of the vas deferens. There were no obvious complications after arteriovenous haemangioma excision, and the right scrotal pain was significantly relieved 1 month later. This article reminds urologists and oncologists that haemangioma can involve the vas deferens and, in addition to spermatic granuloma, might be a cause of post-vasectomy pain syndrome. Cauterization of the vas deferens might have a potential relationship with haemangioma.

Post vasectomy chronic pain: are we under diagnosing vasitis? A case report and review of the literature

Acute vasitis is a rare infection of the vas deferens. Clinical presentation and disease rarity can cause difficulty in correctly diagnosing this condition. Adjuncts to aid diagnosis can be used that include ultrasound scan (USS) or computed tomography. We report a unique case of acute vasitis following vasectomy, reversal and subsequent re-do vasectomy diagnosed using USS.

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.

Osteopathic Manipulative Treatment as a Novel Way to Manage Postvasectomy Pain Syndrome

Postvasectomy pain syndrome (PVPS) can be debilitating and is notoriously difficult to treat, often requiring a multidisciplinary approach. In this case report, osteopathic manipulative treatment (OMT) was used to treat a patient with PVPS. After vasectomy, an otherwise-healthy man experienced chronic right testicular pain, aggravated by exercise, touch, and sexual intercourse, resulting in marital strain and an inability to perform routine fitness activities. Symptoms persisted for 8 years, despite lifestyle modifications, orally administered pain regimens, pelvic floor physical therapy, nerve blocks, steroid injections, epididymectomy, spermatic cord denervation, and counseling. After the patient's urologist suggested orchiectomy, his family medicine physician referred him for OMT. The OMT interventions, applied over a 4-month period, were directed at the lumbar spine, pelvis, pelvic floor, and lower abdomen. After treatment, the patient reported absence of testicular pain most of the time and described his quality of life as "10 times better." Literature review revealed no reports of OMT used to manage PVPS.

How to Treat Chronic Idiopathic Testicular Pain? Scrotoscopy with a Novel Percutaneous Endoscopy Equipment

Background

Management of chronic idiopathic testicular pain may be difficult because of problems identifying the causes. We evaluated “AUTOKLAV”, a novel endourological nephrolithotomy device to diagnose and treat chronic idiopathic testicular pain.

Methods

We divided 103 patients to either scrotoscopy group (SG, n = 64) or open exploration group (OEG, n = 39) between September 2014 and March 2017 at Zhongnan Hospital. Perioperative information, like operating time, length of incision, and wound infections, was carefully recorded during in hospital. Follow-up data, like pain scores improvement, satisfaction with penis appearance, and adverse event, were collected at one month postoperatively.

Results

Finally, both the operating time and length of incision showed better performance for SG (43.6 ± 4.7 versus 51.5 ± 9.0 min; 0.7 ± 0.2 versus 4.1 ± 0.8 cm; both P <0.01). Though the pain improvement had no significant differences between the two groups (2.92 ± 0.99 and 2.14 ± 1.02, p>0.05), SG showed obvious advantages in incidence of wound infections and satisfaction with wound/scrotum appearance (0% versus 2.9%; 96.4% versus 85.3%, both P<0.05).

Conclusions

In conclusion, scrotoscopy using the novel AUTOKLAV device is feasible, has an acceptable complication rate, and can be effective and safe in men with idiopathic chronic testicular pain. Etiologically, secondary inflammatory changes caused by the complete or incomplete torsion of testicular or epididymis appendices or by the existence of stones in the tunica sac might be responsible for the pain.

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.

Chronic Testicular and Groin Pain: Pathway to Relief

The management of patients suffering with chronic testicular and groin pain is very challenging. With increased awareness of men's health, more patients and clinicians are open to talk about this complex problem that affects over 100,000 men/year. The pathogenesis of chronic orchialgia is still not clear, but there are several postulated theories. Treatment options include conservative medical therapy with NSAIDs, antidepressants, anticonvulsants, and narcotics. Surgical options such as targeted microsurgical denervation and microcryoablation can provide permanent durable pain relief. The goal of this article is to review and discuss the management of patients with chronic orchialgia using currently available literature.

Vasectomy: tips and tricks

According to data from the National Study of Family Growth, vasectomy is utilized by 6–13% of American couples for their form of contraception. Physician surveys have shown that over 500,000 men undergo vasectomies per year, and more than 75% of vasectomies are performed by urologists. This chapter provides a brief history of vasectomy, as well as recommendations for preoperative counseling, an overview of the modified no-scalpel vasectomy technique, and a brief description of the complications of vasectomy.

Scrotal Ultrasound for Pain: Low Frequency of Absolute Surgical Indications

OBJECTIVE

To examine the results of scrotal ultrasounds (US) conducted for scrotal or testicular pain and review the pathologic findings of orchiectomies done for lesions that were suspicious for malignancy on US.

MATERIALS AND METHODS

We retrospectively reviewed the indications and findings of all scrotal US completed at our institution from 2002 to 2014. If a patient underwent an orchiectomy for an intratesticular lesion that was concerning for malignancy on US, the pathology report was also reviewed.

RESULTS

There were 18,593 scrotal US performed, with 7,668 (41.2%) conducted for scrotal pain. Of the US performed for pain, 80.4% revealed benign or normal findings, and only 2.2% demonstrated a finding that is an absolute indication for surgery (intratesticular lesion suspicious for malignancy 0.8%, abscess 0.7%, torsion 0.6%, infiltrative process such as lymphoma 0.1%). For those patients undergoing an orchiectomy, 75% had malignancy on pathologic analysis.

CONCLUSION

The majority of the 7668 US performed to evaluate scrotal or testicular pain reveal normal or benign findings. A low percentage demonstrates a finding that necessitates urgent or emergent surgery.

Chronic scrotal pain in young adults

OBJECTIVE

Chronic scrotal pain (CSP) is a common and well recognized symptom of young males presenting to primary care units. Historically, CSP is defined as a testicular pain lasting for over 3 months. However, its etiology and outcome are poorly understood and its management is largely empirical. This study was conducted to examine the frequency, spectrum of pathology and outcome of CSP among young adults.

RESULTS

The medical records of 382,036 young males were reviewed for anamnestic information, physical findings, primary care physician decisions, and final outcome. CSP, defined as scrotal pain longer than 14 days, was recorded in 3084 patients (0.8%). The total number of primary physician's visits due to this complaint was 16,222, with a mean of 5.3 visits per patient (range 1-37). Varicocele was the most common physical finding (54.1%). Other common findings were inguinal hernia (4.5%), genital infection (4.3%), hydrocele (4.2%) and referred pain (3.3%). 252 patients (8.2%) underwent surgical treatment but orchiectomy was not necessary in any patient. In 34.4% no specific etiology could be found. Neither malignant tumors nor testicular torsion were diagnosed in any patient. The prevalence of the diagnoses was similar between the different time groups-15-29 days, 30-59 days and more than 60 days. Considering the similar etiologies CSP over a wide spectrum of time we suggest defining CSP as testicular pain lasting longer than 14 days.

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.

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.

Chronic orchialgia: epidemiology, diagnosis and evaluation

Chronic orchialgia is a vexing condition defined as chronic or intermittent scrotal pain lasting at least three months that significantly interferes with daily activities. There are currently no guidelines regarding the diagnosis and management of this condition despite it being the cause of 2.5-4.8% of urologic clinic visits. Men often present with chronic orchialgia in their mid to late 30s, although the condition can present at any age. A broad differential diagnosis of chronic orchialgia includes epididymitis, testicular torsion, tumors, obstruction, varicocele, epididymal cysts, hydrocele, iatrogenic injury following vasectomy or hernia repair, and referred pain from a variety of sources including mid-ureteral stone, indirect inguinal hernia, aortic or common iliac artery aneurysms, lower back disorders, interstitial cystitis, and nerve entrapment due to perineural fibrosis; approximately 25-50% of chronic orchialgia is idiopathic in nature. In such cases, it is reasonable to consider psychological and psychosocial factors that may be contributing to chronic pain. Invasive testing is not recommended in the work-up of chronic orchialgia.

Characteristics and Etiologies of Chronic Scrotal Pain: A Common but Poorly Understood Condition

Chronic scrotal pain (CSP) is a common and debilitating condition, but the underlying characteristics and etiology of CSP are poorly understood. The objective of this study is to identify the characteristic and etiologies of CSP. Men presenting for management of CSP completed a standardized questionnaire and underwent a complete physical examination. From Feb 2014 to Sep 2015, a total of 131 men (mean age 43) with CSP were studied. The CSP was of long duration (mean of 4.7 ± 5.95 years) and dramatically affected men's lives, with adverse effects on normal activities (71.%), ability to work (51.90%), and sexual functioning (61.8%). 50.4% felt depressed on most days, and 67.17% felt either unhappy or terrible with their present condition. Physical examination revealed that the epididymis was the most common tender area found in 70/131 men (53.43%), though a musculoskeletal source for the pain was found in 9.9%. Neuropathic changes were found in 30%. For close to half of the men (43.5%) we were unable to identify any potential cause for the CSP. This study characterizes the dramatic impact that CSP has on the lives of men, while providing an understanding of the common etiologies.

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.

Probable Statin-Induced Testicular Pain

Objective:

To describe a case of a patient experiencing testicular pain on 3 occasions after taking 3 different statins.

Case Summary:

A 54-year-old man with hyperlipidemia was started on lovastatin therapy. His other medications included aspirin, levothyroxine, buspirone, and atenolol. Seven months after starting lovastatin, the patient experienced testicular discomfort that resolved upon discontinuation of the drug. Afterward, he started simvastatin and again experienced testicular discomfort. The simvastatin was changed to atorvastatin, and the pain resolved. However, 3 months after starting atorvastatin, the patient developed testicular pain, which resolved after the drug was stopped. During each of the episodes, the patient's pain increased when he was sitting, driving, or wearing tight clothing. The Naranjo probability scale indicates that statins probably caused the patient's pain.

Discussion:

Testicular pain is rarely caused by medications. Product labeling for statins does not list urinary adverse events as common. However, labeling for atorvastatin and pravastatin lists rare urologic adverse effects. A literature search did not reveal any previously reported cases of testicular adverse effects from statins. However, statins have been shown to inhibit cholesterol synthesis in the testis. Some data indicate that statins reduce serum testosterone concentrations, but other data indicate that statins have no effect on sex hormones or spermatogenesis. Data are also available indicating that aspirin might affect testosterone concentrations and testicular function. It is difficult to know whether either of the above hormonal mechanisms was associated with our patient's testicular discomfort, but the time course and challenge/rechallenge aspects of the case suggest that the statins were the cause.

Conclusions:

Urologic adverse effects of statins rarely occur but should not be overlooked by medical providers.

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.

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 calculi in clinical practice and their role in scrotal pain: A prospective study

PURPOSE

Scrotal calculi are rare, and their clinical significance is uncertain. Scrotal pain is a frequent, hard-to-manage problem in urology clinics. Our purpose in this study was to determine the relationship between the presence of scrotal calculi and scrotal pain in a prospective manner.

METHODS

Sonography and color Doppler ultrasound of the scrotum were performed in 758 consecutive patients referred with scrotal pain. The pain was rated by using an 11-point numeric rating scale; scores were compared among patients with scrotal calculi with and without additional scrotal pathology.

RESULTS

Scrotal calculi were detected in 73 of the 758 patients (9.6%). Scrotal pain (n = 50 [61%]) and a palpable mass in the scrotum (n = 25 [30.5%]) were the most common complaints in patients with scrotal calculi. Hydrocele (n = 17 [29.8%]) and varicocele (n = 15 [26.3%]) were the most commonly associated abnormalities; there was a statistically significant association between the presence of scrotal calculi and hydrocele (p < 0.01). Scrotal pain was present in 61 (83.5%) patients with scrotal calculi, and this association was significant (p < 0.001). The presence of scrotal pain and the correlation between location of calculi and pain in patients without additional scrotal abnormalities were also significant (p = 0.04 and p < 0.004, respectively).

CONCLUSIONS

The prevalence of scrotal calculi was 9.6%, and hydrocele was found to be associated with scrotal calculi. We also found a significant relationship between the presence of calculi and scrotal pain. Because the etiology of scrotal pain is essential for appropriate treatment, scrotal calculi should be kept in mind when making a differential diagnosis of scrotal pain. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 43:406-411, 2015.

Microsurgical Spermatic Cord Denervation as a Treatment for Chronic Scrotal Content Pain: A Multicenter Open Label Trial

PURPOSE

We prospectively evaluated the results of microsurgical spermatic cord denervation in a series of patients with chronic scrotal content pain in a multicenter study, including 1 center in Germany and 3 centers in Chile.

MATERIALS AND METHODS

A total of 50 patients with chronic scrotal content pain more than 3 months in duration were prospectively selected for standardized operative microsurgical spermatic cord denervation as pain treatment. In all patients preoperative management included a positive response to a spermatic cord block test with local anesthesia. Pain severity was assessed using an analog visual pain scale (range 0 to 10) for 30 consecutive days. A total of 52 testicular units were operated on using a subinguinal approach. In all cases a surgical microscope was used to identify the arteria testicularis.

RESULTS

No intraoperative complications were observed and no testicular units were lost. Two reoperations were performed, including 1 for hematocele and 1 for hydrocele. Six months after surgery 40 patients (80%) were completely pain-free. In 6 patients (12%) intermittent testicular discomfort persisted, which could be managed by acetaminophen on demand. Four patients (8%) had no change in pain severity after surgery.

CONCLUSIONS

After proper selection of patients microsurgical spermatic cord denervation seems to be a safe and efficient procedure to treat chronic scrotal content pain. Considering the limitations of the study, a randomized, controlled trial with longer followup is highly warranted.

Drug delivery to the testis: current status and potential pathways for the development of novel therapeutics

Nanotechnology has been increasingly utilized for the targeting and delivery of novel therapeutic agents to different tissues and cell types. The current therapeutic options for testicular disorders fall short in many instances due to difficulty traversing the blood-testis barrier, systemic toxicities, and complicated dosing regiments. For testicular tissue, potential targeting can be obtained either via anatomic methods or specific ligands such as luteinizing hormone or follicle-stimulating hormone analogs. Potential novel therapeutic agents include DNA, RNA, cytokines, peptide receptor antagonists, peptide receptor agonists, hormones, and enzymes. Nanotherapeutic treatment of testicular cancer, infertility, testicular torsion, orchalgia, hypogonadism, testicular infections, and cryptorchidism within the framework of potential target cells are an emerging area of research. While there are many potential applications of nanotechnology in drug delivery to the testis, this remains a relatively unexplored field. This review highlights the current status as well as potential future of nanotechnology in the development of novel therapeutics for testicular disorders.

Pediatric chronic orchialgia: patient population and patterns of care

OBJECTIVE

A major hurdle in management of any chronic pain syndrome is understanding the population in which it occurs. We describe our pediatric population of patients with peripubertal and postpubertal chronic orchialgia.

PATIENTS AND METHODS

Pediatric patients ≥ 10 years of age seen between 2002 and 2012 were identified by ICD code 608.9, Male Genital Disorder NOS. Patients were included if they had orchialgia without identifiable cause lasting >3 months. Patient history, diagnostic evaluations, treatments, and outcomes were assessed.

RESULTS

Seventy-nine pediatric patients were identified. The mean age was 13.3 years (range 10-18); mean duration of orchialgia was 16.3 months (range 3-85). Thirty-three of 79 (42%) had concomitant medical conditions and/or psychiatric-behavioral issues. The mean follow-up was 7.1 months (range 0-70.4) with 41/79 (52%) having more than one office visit follow-up. Eleven patients were referred to a pediatric pain clinic; 10 out of 11 (91%) were evaluated there. Overall, 16 out of 41 (39%) had resolution of pain: nine out of 41 (22%) responding to conservative management vs seven of 10 (70%) responding to pain clinic management (3 to anti-neuropathic medications, 4 to nerve block).

CONCLUSION

Many pediatric patients with chronic orchialgia have co-morbidities amenable to multidisciplinary collaborative coordination of care. Referral to pediatric pain clinic can be of significant benefit.

Post-vasectomy depression: a case report and literature review

Vasectomy is a commonly performed and relatively safe procedure, with low reported rates of psychological morbidity, though there is some variability across studies. Depression following a vasectomy is relatively infrequent. A married man aged 30 developed a chronic depressive episode, lasting four years and resistant to an adequate trial of fluoxetine, following a vasectomy. His depression was heralded by a post-operative panic attack, and was accompanied by medically unexplained symptoms and the attribution of all his symptoms to the procedure – a belief that was shared by his family. Psychological complications of vasectomy have generally been studied under four heads: sexual dysfunction, effects on marital relationships, chronic post-operative pain, and other complications including anxiety and depression. These complications have generally been reported at higher rates in developing countries, and are linked to poor knowledge about the procedure and inadequate pre-operative counseling. The implications of the existing literature for the patient’s current complaints, and the mechanisms and risk factors involved, are discussed in the light of existing research. Suggestions for the prevention and treatment of post-vasectomy depression are also outlined.

Microsurgical denervation of rat spermatic cord: safety and efficacy data

OBJECTIVE

To describe a microsurgical technique for denervation of the spermatic cord and use of multiphoton microscopy (MPM) laser to identify and ablate residual nerves after microsurgical denervation. To evaluate structural and functional changes in the rat testis and vas deferens after denervation.

MATERIALS AND METHODS

Nine Sprague-Dawley rats were divided into three experimental groups: sham, microsurgical denervation of the spermatic cord (MDSC), and MDSC immediately followed by laser ablation with MPM. At 2 months after surgery, we assessed testicular volume, functional circulation of the testicular artery with Doppler, patency of the vas deferens, and histology of the testis and vas deferens.

RESULTS

There was a significant decrease in the median number of nerves remaining around the vas deferens with MDSC alone (3.5 nerves) or MDSC with MPM (1.5 nerves) compared with sham rats (15.5 nerves) (P = 0.003). Although, MDSC with MPM resulted in the fewest remaining nerves, this result was similar to MDSC alone (P = 0.29). No deleterious effects on spermatogenesis or vas patency were seen in the experimental groups when compared with the sham rats.

CONCLUSION

A microsurgical approach can be used to effectively and safely denervate the rat spermatic cord with minimal changes to structure and function of the testis and vas deferens. MPM can be used as an adjunct to identify and ablate residual nerves after MDSC.

Prospective double-blind preoperative pain clinic screening before microsurgical denervation of the spermatic cord in patients with testicular pain syndrome

Testicular pain syndrome (TPS), defined as an intermittent or constant pain in one or both testicles for at least 3 months, resulting in significant reduction of daily activities, is common. Microsurgical denervation of the spermatic cord (MDSC) has been suggested as an effective treatment option. The study population comprised 180 TPS patients admitted to our outpatient urology clinic between 1999 and 2011. On 3 different occasions, patients were offered a double-blind, placebo-controlled temporary blockade of the spermatic cord. A single blockade consisted of 10 mL 2% lidocaine, 10 mL 0.25% bupivacaine, or 10 mL 0.9% sodium chloride. If the results of these blockades were positive, MDSC was offered. All MDSCs were performed by a single urologist (M.T.W.T.L.) using an inguinal approach. Pain reduction was determined at prospective follow-up. This study evaluated 180 patients. Most patients (61.1%) had undergone a scrotal or inguinal procedure. Patients had complaints during sexual activities (51.7%), sitting (37.5%), and/or cycling (36.7%); 189 randomized blockades were offered to all patients. There was a positive response in 37% and a negative response in 51%. MDSC was performed on 58 testicular units, including 3 patients with a negative outcome of the blockades. At mean follow-up of 42.8 months, 86.2% had a ≥ 50% reduction of pain and 51.7% were completely pain free. MDSC is a valuable treatment option for TPS patients because in this study 86.2% experienced a ≥ 50% reduction of pain. To prevent superfluous diagnostics and treatment, it is mandatory to follow a systematic protocol in the treatment of TPS.

Chronic scrotal and inguinal pain after orchidopexy in a 13-year-old boy, treated by pulsed radiofrequency of the dorsal ganglia

Chronic scrotal pain can be a difficult clinical entity to treat. Many different treatment options have been proposed. We describe the case of a young boy with chronic scrotal and inguinal pain on the right side, following two orchidopexies. After many therapies had failed, we treated the dorsal root ganglia of thoracic 12, lumbar 1 and lumbar 2 with pulsed radiofrequency, finally resulting in alleviation of his pain.

Physiological and pharmacological aspects of the vas deferens-an update

The vas deferens, a muscular conduit conveying spermatozoa from the epididymis to the urethra, has been used as a model tissue for smooth muscle pharmacological and physiological advancements. Many drugs, notably α-adrenergic antagonists, have effects on contractility and thus normal ejaculation, incurring significant side effects for patients that may interfere with compliance. A more thorough understanding of the innervation and neurotransmitter pharmacology of the vas has indicated that this is a highly complex structure and a model for co-transmission at the synapse. Recent models have shown clinical scenarios that alter the vas contraction. This review covers structure, receptors, neurotransmitters, smooth muscle physiology, and clinical implications of the vas deferens.

Role of orchiectomy in severe testicular pain after inguinal hernia surgery: audit of the Finnish Patient Insurance Centre

PURPOSE

Testicular ischemia and necrosis are uncommon complications after inguinal hernioplasty. Our aim was to evaluate the incidence of severe urological complications related to adult inguinal hernia surgery in Finland with special reference to orchiectomy in relieving intractable chronic testicular pain.

METHODS

All urological complications related to inguinal hernia surgery during 2003-2010 were analysed from the Finnish Patient Insurance Centre. The patients with intractable chronic scrotal or testicular pain that resulted in orchiectomy were re-evaluated after a median follow-up of 7 years (range 2-15 years). The operative factors related to chronic testicular pain and atrophy were analysed using multiple regression analysis.

RESULTS

Altogether 62 urological complications (from 335 litigations) were recorded from 92,000 inguinal hernia operations. The distribution of claimed urological complications consisted of 34 testicular injuries, ten bladder perforations, seven massive scrotal haemorrhage or 11 miscellaneous injuries. Seventeen atrophic testes were left in situ and 17 (six early < 7 days, 11 late > 8 days) orchiectomies were performed due to necrosis or chronic testicular pain syndrome. In the conservative group of moderate scrotal or testicular pain (n = 17), all patients had late pain symptoms (>8 days), but pain was not so severe that orchiectomy was attempted. Using a multivariate analysis, postoperative infections were associated with chronic testicular or scrotal pain and atrophy, but hospital status, surgeon's training level, laparoscopic or open operation, type of hernia or use of mesh did not correlate with testicular injuries. During follow-up, 11/17 (65%) patients with orchiectomy were free of testicular pain.

CONCLUSION

Urological injuries form one-fifth of the major complications after inguinal hernioplasty. Orchiectomy appears to help the majority of patients with severe testicular pain syndrome.

Trifecta nerve complex: potential anatomical basis for microsurgical denervation of the spermatic cord for chronic orchialgia

PURPOSE

We identified structural abnormalities in the spermatic cord nerves that may explain how microsurgical denervation of the spermatic cord provides pain relief in patients with chronic orchialgia.

MATERIALS AND METHODS

We retrospectively reviewed a prospective database to compare spermatic cord biopsy specimens from 56 men treated with a total of 57 procedures for microsurgical denervation of the spermatic cord for chronic orchialgia vs a control group of men without pain treated with cord surgery, including varicocelectomy in 4 and radical orchiectomy in 6. Tissue biopsies were obtained from mapped regions of the spermatic cord in all cases. Biopsies stained with hematoxylin and eosin were examined by an independent pathologist. Three human cadaveric spermatic cords were dissected to confirm localization of the nerve distribution identified on pathological mapping.

RESULTS

We identified a median of 25 small diameter (less than 1 mm) nerve fibers in the spermatic cord. Of the 57 procedures for orchialgia 48 (84%) showed wallerian degeneration in 1 or more of these nerves but only 2 of 10 controls (20%) had such degeneration (p = 0.0008). In decreasing order of nerve density the 3 primary sites (trifecta nerve complex) of these changes were the cremasteric muscle fibers (19 nerves per patient), perivasal tissues and vasal sheath (9 nerves per patient), and posterior cord lipomatous/perivessel tissues (3 nerves per patient). Cord nerve distribution mapped by the biopsies was confirmed by cadaveric dissection.

CONCLUSIONS

In men with chronic orchialgia there appears to be wallerian degeneration in reproducible patterns in the spermatic cord nerve fibers. Transection of these nerves may explain the effect of the denervation procedure.

Microdenervation of the spermatic cord for chronic scrotal content pain: single institution review analyzing success rate after prior attempts at surgical correction

PURPOSE

Microdenervation of the spermatic cord is an effective treatment for men with intractable scrotal content pain. We evaluated a single center experience, analyzing patients in whom prior surgical attempts had failed to correct pain who subsequently underwent microdenervation of the spermatic cord.

MATERIALS AND METHODS

A retrospective chart review of 68 patients who underwent microdenervation of the spermatic cord from 2006 to 2010 was performed. Prior ipsilateral surgical procedures with the intent to correct scrotal content pain were selected, identifying 31 testicular units.

RESULTS

Chart review was performed on 68 men with mean age of 42 years at presentation and a mean followup of 10 months. Patients in whom prior surgical correction had failed and who subsequently had microdenervation of the spermatic cord had a mean postoperative pain score of 3 (range 0 to 10) with an average decrease in pain of 67%. Those who had not undergone a prior attempt at surgical correction had a mean post-microdenervation of the spermatic cord pain score of 2 (range 0 to 10) and an average pain decrease of 79% which did not differ statistically from those in whom prior surgery failed. In addition, 50% of men who had undergone surgery before microdenervation of the spermatic cord had complete relief of pain after microdenervation of the spermatic cord vs 64% of those who had not undergone previous surgery.

CONCLUSIONS

Men with chronic scrotal content pain in whom prior attempts to correct pain have failed have similar, albeit lower, success rates as those without prior surgical intervention. Therefore, men with chronic scrotal content pain in whom prior surgical management has failed and who have a positive spermatic cord block should be considered candidates for microdenervation of the spermatic cord.

Pediatric chronic orchalgia

INTRODUCTION

Chronic orchalgia, defined as testicular pain lasting > 3 months and interfering with normal activities, is neglected in the pediatric literature. We describe our experience with the evaluation and treatment of pediatric chronic orchalgia patients.

MATERIALS AND METHODS

Charts were screened to identify patients meeting the criteria for chronic orchalgia. Charts were further reviewed to record the history and physical exam, diagnostic tests, treatment and outcomes.

RESULTS

65/982 patients met the criteria for chronic orchalgia. Mean age was 13 and mean duration of pain was 8.6 months. Physical exam findings were normal in 46 patients (70%). 59 patients were managed conservatively with resolution (10/59, 17%) or a single visit (36/59, 61%) in 78%. 13/59 (22%) patients showed either minor improvement or no change in symptoms. 5 non-responding patients were managed by the anesthesia pain service; 4 received epidurals with or without additional oral pain medications with 3 experiencing significant pain improvement.

CONCLUSION

Conservative management of chronic orchalgia allowed symptoms to subside in the majority of cases. We recommend patients be treated with conservative measures for 1-2 months. If this fails, early involvement of the anesthesia pain service can offer treatment modalities such as epidural analgesia. Surgical management in the face of a normal physical exam does not seem to have a role.