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

Chronic scrotal content pain: the experiences of patients undergoing microsurgical spermatic cord denervation

Background

Chronic scrotal content pain, sometimes referred to as chronic orchialgia, is a common urological condition that gives rise to persistent and often severe painful stimuli to the scrotum and surrounding structures. Despite its relative commonality, accounting for over 2% of urological visits, chronic scrotal content pain is complex to manage and patients may be required to access multiple providers and undergo invasive procedures, including microsurgical spermatic cord denervation (MSCD) surgery.

Objective

The objective of this study was to understand the experiences and perspectives of persons with chronic scrotal content pain and accessing MSCD surgery.

Design

An exploratory qualitative design, guided by interpretive description and integrated knowledge translation, was adopted.

Methods

We conducted in-depth qualitative interviews with six patients with chronic scrotal content pain who underwent MSCD surgery in a surgical center in Western Canada. Data were analyzed thematically.

Results

Analysis of the study data resulted in three core themes: living with chronic scrotal content pain, quality of life, and MSCD procedure and outcomes. We highlight the debilitating nature of pain and the broad impacts upon health, quality of life, and social functioning. Participants described how MSCD surgery offered an effective solution for persistent and debilitating pain. For the participants, MSCD surgery offered hope and the chance to regain their normality.

Conclusion

For those with chronic scrotal content pain, access to a pain specialist, along with the adoption of a biopsychosocial approach to pain and early access to MSCD surgery, may improve patient experiences and outcomes. Considering the high prevalence of urological pain, greater interdisciplinary care is needed in order to support more effective and timely management.

Men With Chronic Orchialgia Exhibit Differential Neuroinflammatory Gene Expression Relative to Asymptomatic Controls

OBJECTIVE

To identify differences in neuroinflammatory gene expression in individuals with chronic orchialgia (CO) compared to asymptomatic controls.

METHODS

Vas deferens, spermatic cord fascia, blood, and urine were collected from 9 men with CO at time of microscopic spermatic cord denervation and 7 asymptomatic controls at time of vasectomy. RNA was isolated and analyzed with the NanoString Human Neuroinflammation panel. Data were normalized, gene expression fold changes and enriched pathways relative to asymptomatic controls were determined. Gene expression was considered significantly different if there was a >2-fold change and P-value <.05 relative to controls.

RESULTS

Mean patient age was 51 years and median symptom duration 12 months. There were 26 genes with significantly differential expression in vas deferens. cFos, a marker of nociceptive pain, had the greatest difference (30.2-fold change, P <.000001). Enriched pathways in vas deferens included nerve function, matrix remodeling, and innate immune responses. In fascia, cFos also had the greatest differential expression (38-fold, P = .000002), followed by S100A12 (11-fold, inducer of innate immune response). Enriched pathways in fascia included nerve function and inflammation. In blood, there were no differentially expressed genes, and in urine there were 95 differentially expressed genes.

CONCLUSION

Men with CO have a diverse set of neuroinflammatory genes with differential expression in tissue and urine relative to healthy controls. These findings confirm pathologic changes in tissue targeted by denervation surgery, and suggest molecular changes in neuropathic pain that could lead to biomarker identification and novel treatment.

Microsurgical Denervation of the Spermatic Cord: A Historical Perspective and Recent Developments

INTRODUCTION

The management of chronic scrotal pain is long and varied, with historical treatment algorithms typically ending with orchiectomy. Microsurgical denervation of the spermatic cord (MDSC) is a testicle-sparing option for patients who have failed conservative treatment options and over its forty-year history has seen many technical refinements.

OBJECTIVES

To review the history and development of MDSC and discuss the outcomes of different surgical techniques.

METHODS

A literature review using PubMed and Google Scholar was conducted to identify studies pertaining to surgical treatment of CSP, MDSC, and outcomes. Search terms included "chronic," "scrotal pain," "orchialgia," "spermatic cord," "denervation," and "microsurgery."

RESULTS

We included 21 case reports and series since the first seminal paper describing MDSC technique in 1978. Additional studies that challenged existing conventions or described novel techniques are also discussed. The current standard procedure utilizes a subinguinal incision and a surgical microscope. Open, robotic, and laparoscopic approaches to MDSC have been described, but access to minimally invasive instruments may be limited outside of developed nations. Pain reduction following preoperative spermatic cord predicts success of MDSC. Methods for identifying and preserving the testicular and deferential arteries vary depending on surgeon preference but appear to have comparable outcomes. Future developments in MDSC involve targeted denervation, minimizing collateral thermal injury, and alternative techniques to visualize arterial supply.

CONCLUSION

For patients suffering from CSP, MDSC is a well-studied technique that may offer appropriately selected patients' relief. Future investigation comparing targeted vs full MDSC as well as in vivo study of new techniques are needed to continue to improve outcomes. Sun HH, Tay KS, Jesse E, et al. Microsurgical Denervation of the Spermatic Cord: A Historical Perspective and Recent Developments. Sex Med Rev 2022;XX:XXX-XXX.

Non-pharmacological treatments for chronic orchialgia: A systemic review

Objective

: To review the outcomes of various therapeutic modalities that can be offered to patients with chronic orchialgia (CO) after failed conservative treatment.

Methods

: A literature search was conducted using the PubMed and MEDLINE databases searching for articles exploring different CO treatment modalities. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach was used to report the results of the literature search.

Results

: A total of 34 studies were included for qualitative analysis. Most of the studies explored microsurgical spermatic cord denervation (MSCD; n = 19). Eight studies involved devices and interventions directed at blocking nerve sensations (pulsed radiofrequency stimulation, n = 5; transcutaneous electrical nerve stimulation, n = 1; cryoablation, n = 1; and mechanical vibratory stimulation, n = 1). Five studies reported on vasectomy reversal as a modality to relieve post-vasectomy pain syndrome (PVPS), while two studies explored the outcomes of orchidectomy on pain relief in patients with CO.

Conclusion

: Several treatment methods are available in the urologist’s armamentarium for the treatment of CO. MSCD appears to be an appealing treatment modality with encouraging outcomes. Neuropathic pain can be managed with a number of relatively non-invasive modalities. Vasectomy reversal is a sound treatment approach for patients with PVPS and ultimately orchidectomy is a terminal approach that can be discussed with patients suffering from intractable pain.

Robotic microsurgical spermatic cord denervation for chronic orchialgia: a case series

Context

Chronic orchialgia is a frustrating urologic condition that is commonly refractory to conservative modes of therapy. Microscopic spermatic cord denervation is a proven solution for patients who do not achieve relief from nonsurgical treatments. However, current widely used techniques require additional training in microsurgery.

Objective

To describe an adaptation and improvement of spermatic cord microdenervation technique that leveraged the robotic surgical training common for new urologists and is also accessible for urologists not specifically trained in microsurgery.

Methods

Robotic-assisted microdenervation of the spermatic cord was performed in three patients using a fluorescence vascular imaging tool to improve visualization of vascular structures (Firefly™; Innovative Surgical, Sunnyvale, CA, USA), along with a tissue matrix allograft to allow for better healing (AminoFix™; MiMedx®, Marietta, GA, USA).

Results

All three patients (100%) experienced postoperative resolution of their chronic orchialgia, and none reported any new pain.

Conclusion

Utilization of robotic-assisted surgery offers more urologists the ability to use familiar techniques to treat chronic orchialgia when conservative measures are unsuccessful.

Resolution of post-traumatic chronic testicular pain in a pediatric patient after microsurgical denervation of the spermatic cord: a case report

PURPOSE

Chronic scrotal content pain, chronic orchialgia, or testicular pain can present after trauma, vasectomy, and hernia repair, among other triggers. Microsurgical denervation of the spermatic cord is an option for definitive pain control. While this practice is established in adult urology, access to diagnostic intervention and definitive denervation surgery is limited in the pediatric population.

CLINICAL FEATURES

We report a case of definitive resolution of testicular pain with microsurgical denervation of the spermatic cord in a pediatric patient with post-traumatic chronic orchialgia that significantly reduced his daily activities and worsened his anxiety prior to this treatment. The patient underwent attempts at conservative medication-based management, followed by diagnostic spermatic cord nerve block before definitive denervation surgery.

CONCLUSIONS

The incidence of chronic pain in pediatrics is substantial and is estimated to be around 20%. Orchialgia remains difficult and problematic to treat. Mental health diagnoses such as anxiety and depression are also significantly associated with chronic pain. Following consideration and implementation of steps for all these concerns, a diagnostic block and microsurgical denervation led to successful resolution of chronic testicular pain in a pediatric patient.

Current trends and therapies in orchialgia management

The management of pain is a complex condition that will be encountered by most practicing clinicians. In the genitourinary community, testicular pain may be classified as acute or chronic. Initial evaluation of chronic groin and scrotal content pain (CGSCP) begins with a detailed history and physical examination to elucidate the presenting pathology. Multiple therapy algorithms have been proposed with no definitive consensus; however, most begin with conservative intervention and medical management prior to advancing to more invasive procedures. Surgical approaches may range from reconstruction, as in vasovasostomy for post-vasectomy pain syndrome, to excision of the offending agent, as in epididymectomy. This review seeks to focus on chronic pain in the genitourinary community and review techniques of pain management in the current intervention for orchialgia, as well as identify future methods of treatment.

Preoperative Modified Spermatic Cord Block Predicts Success in Candidates for Microscopic Spermatic Cord Denervation

OBJECTIVE

To examine the utility of a modified spermatic cord block (MSCB) that targets known contributors to refractory chronic scrotal content pain (CSCP) at predicting postoperative pain relief following a microscopic spermatic cord denervation (MSCD).

METHODS

A MSCB was performed in all patients with refractory CSCP. This was performed by injecting anesthetic circumferentially around the vas deferens and over the external ring. Patients with >50% pain reduction were offered MSCD. Baseline, post-block, and postoperative pain was assessed. Age, prior groin surgery, and post-block pain free period were recorded. A multivariate linear regression model was used to determine predictors of surgical success.

RESULTS

Fifty-two patients underwent a MSCB. Forty-six (88%) had an adequate response and underwent MSCD. All patients saw improvement in pain postoperatively with an average reduction of 80% (4 < 50%; 7 50-69%; 35 ≥ 70%). On multivariate linear regression analysis, pain reduction following MSCD was an independent predictor of postoperative improvement (P < 0.001). No other factors, including post-block pain free period or prior surgery predicted success.

CONCLUSIONS

The described MSCB can be utilized as an independent predictor of success following MSCD. Post-block pain free period was not associated with postoperative pain level. The MSCB may help identify candidates for MSCD that would be missed with the traditional block.

Microscopic spermatic cord denervation for chronic orchialgia/chronic scrotal content pain: operative outcomes and predictors of failure

Background

To describe our institutional outcomes with microscopic spermatic cord denervation (MSCD) for chronic scrotal content paint (CSCP) and identify predictors of treatment failure.

Methods

Retrospective chart review was performed to identify all MSCD performed by two surgeons at a single institution from 2010–2019. Patient demographic data and operative outcomes were collected. Patients were excluded from analysis if no post-operative follow up was available. Success was defined as complete resolution of bothersome pain. Multivariable logistic regression was utilized to identify predictors of treatment failure.

Results

During the study period, 101 patients were identified in which 113 MSCD procedures were performed. Final analysis included 103 procedures across 93 patients. Mean age was 41.8 years (SD 13.2), mean BMI was 29.2 kg/m² (SD 5.96) and median months of pain preceding surgery were 24 (range, 3–300 months). Overall, 75/103 (73%) MSCD were successful. Of the failures, 5 patients had recurrence of pain greater than 6 months after surgery. Only the presence of pelvic floor muscle spasm (PFMS) independently predicted MSCD failure (OR 3.95, P=0.02). 9 of 19 (47%) patients with PFMS experienced treatment failure, while 19 of 84 (23%) without PFMS experienced failure.

Conclusions

MSCD offers a therapeutic option for patients with refractory CSCP. The presence of PFMS is associated with lower surgical success rates. Patients with pre-operatively identified PFMS should be counseled regarding a higher risk of treatment failure.

High Inguinal Microsurgical Denervation of the Spermatic Cord for Chronic Scrotal Content Pain: A Novel Approach for Adult and Pediatric Patients

OBJECTIVE

To improve the technique and results of microsurgical denervation of the spermatic cord (MDSC) for men with chronic scrotal content pain, we describe a novel approach at the level of the internal inguinal ring for the complete transection of the nerves running both inside and outside the spermatic cord for adults and children.

METHODS

A retrospective review of 52 patients (64 testicular units) who underwent high inguinal MDSC was performed. Visual analogue scale (VAS, 1-10) scores were compared with before and every 3 months after the surgery. Depressive symptoms were assessed by the Beck Depression Inventory. Hormonal evaluations were performed before and 6 months after the surgery.

RESULTS

The average patient age was 52.4 years (12-78); including 6 pediatric cases. The mean operative time was 67 minutes per testicular unit, and there were no major complications. The mean pre- and post-MDSC VAS scores were 8.3 and 2.5, respectively (P < .0001). Forty-six (88%) cases showed positive responses after MDSC, and multivariate analysis showed that pain outside the scrotum and depressive symptoms were predictors of MDSC failure (P < .05, odds ratio: 15.27 and 12.56, respectively).

CONCLUSION

For both adult and pediatric patients, high inguinal MDSC is an effective and safe management option, including testicular function, for the chronic scrotal content pain that is refractory to medical management. We find that the high inguinal approach is easier in our experience than the subinguinal approach because of fewer divisions of veins, a larger diameter of the spermatic artery.

Salvage Ultrasound-guided Targeted Cryoablation of The Perispermatic Cord For Persistent Chronic Scrotal Content Pain After Microsurgical Denervation Of The Spermatic Cord

OBJECTIVE

To assesses the efficacy of ultrasound-guided targeted cryoablation (UTC) of the perispermatic cord as a salvage treatment for patients who failed microsurgical denervation of the spermatic cord.

METHODS

Retrospective review of 279 cases (221 patients: 58 bilateral) undergoing UTC between November 2012 and July 2016, performed by 2 fellowship trained microsurgeons. UTC was performed using a 16-gauge cryo needle (Endocare, HealthTronics, Austin, TX). Branches of the genitofemoral, ilioinguinal, and inferior hypogastric nerves were cryoablated medial and lateral to the spermatic cord at the level of the external inguinal ring. Level of pain was measured preoperatively and postoperatively using the visual analog scale and Pain Index Questionnaire-6 (QualityMetric Inc., Lincoln, RI).

RESULTS

Median age was 43 years, operative duration 20 minutes, and postoperative follow-up 36 months (24-60). Subjective visual analog scale outcomes: 75% significant reduction in ain (11% complete resolution and 64% ≥50% reduction in pain). Objective Pain Index Questionnaire-6 outcomes: 53% significant reduction at 1 month (279 cases), 55% at 3 month (279 cases), 60% at 6 month (279 cases), 63% at 1 year (279 cases), 65% at 2 years (275 cases), 64% at 3 years (232 cases), 59% at 4 years (128 cases) and 64% at 5 years (53 cases) post-op.

COMPLICATIONS

2 wound infections, 4 penile pain cases (resolved in a few months).

CONCLUSION

UTC of the perispermatic cord is a safe potential treatment option for the salvage management of persistent chronic scrotal pain in patients who have failed microsurgical denervation of the spermatic cord.

Chronic Scrotal Pain

PURPOSE OF REVIEW

Chronic scrotal pain (CSP) is a common yet poorly understood condition, with significant impacts on overall quality of life. Many patients will have sought evaluation and management from multiple providers in an attempt to find a solution for their pain.

RECENT FINDINGS

Despite many emerging treatments for CSP and further understanding of the potential etiologies and pathophysiological basis of the condition, its natural history is poorly understood. It is also important to recognize the psychosocial impact of CSP and consider formal referral for psychological evaluation and treatment if the patient endorses significant psychiatric responses to pain. It is important to also recognize the neuropathic component of pain that may arise in patients with CSP. Neuropathic medications show promise as a narcotic-sparing pharmacological intervention. There are promising surgical options for CSP including microsurgical denervation of the spermatic cord. This article highlights the current best practice recommendations on the evaluation and management of chronic scrotal pain.

Microdenervation of the spermatic cord for post-vasectomy pain syndrome

OBJECTIVE

To evaluate the outcomes of patients who underwent microdenervation of the spermatic cord (MDSC) for post-vasectomy pain syndrome (PVPS) at our institution.

METHODS

A retrospective study of all patients who underwent MDSC for PVPS by a single surgeon between March 2002 and October 2016 was performed. Pain was documented using the numerical rating scale (NRS). Spermatic cord block (SCB) was performed on all patients, and success was defined as NRS score ≤1 for >4 h. All patients had failed medical therapy prior to MDSC. All previous procedures for PVPS had been performed elsewhere. Surgical success was defined as a postoperative NRS score of ≤1.

RESULTS

A total of 27 patients with 28 scrotal units underwent MDSC for PVPS. The median (1st quartile; 3rd quartile) follow-up was 10 (2; 16.5) months. The median (range) duration of pain prior to surgery was 57 (8-468) months. Pain was bilateral in 14 (52%), left-sided in eight (30%) and right-sided in five patients (19%). Data on SCB were available for 23 patients, with a success rate of 96%. The median (range) preoperative pain NRS score was 7 (2-10). The median (range) pain score after SCB on the NRS scale was 0 (0-5). The median (range) postoperative pain score on the NRS was 0 (0-9). Overall success was achieved in 20 of 28 testicular units (71%). Patients with involvement of multiple structures in the scrotum (i.e. testis, epididymis, spermatic cord) had a success rate of 81% and were more likely to have a successful surgery (P < 0.001). Five patients had failed a prior epididymectomy and three had failed a vaso-vasostomy for PVPS; this had no correlation with the success of MDSC (P = 0.89).

CONCLUSION

The MDSC procedure is a reasonably successful, durable and valuable approach for PVPS, especially when pain involves multiple structures in the scrotum (testis, epididymis, spermatic cord). MDSC was equally efficacious in patients who had previously failed a procedure for PVPS. No patient had a worsening NRS score after MDSC. This is the largest study to date evaluating MDSC for the treatment of PVPS.

Targeted Robotic Assisted Microsurgical Denervation of the Spermatic Cord for the Treatment of Chronic Orchialgia or Groin Pain: A Single Center, Large Series Review

PURPOSE

Microsurgical denervation of the spermatic cord is a treatment option for chronic orchialgia refractory to conservative treatment. A recent study showed specific nerve fibers as the possible cause of chronic orchialgia. Our goal was to present the outcomes of ligation of these nerves using a technique of targeted robotic assisted microsurgical denervation of the spermatic cord.

MATERIALS AND METHODS

We retrospectively reviewed the records of 772 patients who underwent targeted robotic assisted microsurgical denervation of the spermatic cord from October 2007 to July 2016. Selection criteria were chronic testicular pain more than 3 months in duration, failed conservative treatments, negative neurological and urological workup, and temporary resolution of pain with a local anesthetic spermatic cord block. Targeted robotic assisted microsurgical denervation of the spermatic cord was performed. Pain was assessed preoperatively and postoperatively using a subjective visual analog scale and objectively with the standardized and validated PIQ-6 (Pain Impact Questionnaire-6) score.

RESULTS

Followup data were available on 860 cases. During a median followup of 24 months (range 1 to 70) 718 cases (83%) showed a significant reduction in pain and 142 (17%) had no change in pain by subjective visual analog scale scoring. Of cases with a significant reduction in pain 426 (49%) had complete resolution and 292 (34%) had a 50% or greater reduction. Objective PIQ-6 analysis showed a significant reduction in pain in 67% of patients 6 months postoperatively, in 68% at 1 year, in 77% at 2 years, in 86% at 3 years and in 83% at 4 years.

CONCLUSIONS

Targeted robotic assisted microsurgical denervation of the spermatic cord is an effective, minimally invasive approach with potential long-term durability in patients with refractory chronic orchialgia.

Micro-Denervation of the Spermatic Cord for Post-Vasectomy Pain Management

INTRODUCTION

Post-vasectomy pain syndrome (PVPS) is a challenging problem for the practicing urologist because of its unclear pathophysiology and no clearly established protocol for evaluation or treatment. PVPS is defined as at least 3 months of chronic or intermittent scrotal content pain after a vasectomy procedure once other etiologies for the pain have been ruled out.

AIM

To systematically review the current literature on the effectiveness of micro-denervation of the spermatic cord (MDSC) for PVPS.

METHODS

A systematic literature search using PubMed, Scopus, Medline, Embase, and Cochrane databases for all reports pertaining to PVPS using the Medical Subject Heading terms post vasectomy pain syndrome and micro-denervation of spermatic cord through February 2017.

MAIN OUTCOME MEASURES

Scrotal content pain after MDSC for PVPS.

RESULTS

There were nine retrospective studies evaluating MDSC for chronic testicular pain. After omitting repeated series, there were 213 patients who underwent MDSC for chronic orchialgia. Only one study specifically reviewed the outcomes of patients who underwent MDSC for PVPS. In this study, 17 patients underwent MSDC for PVPS, with 13 (76.5%) reporting complete relief of pain at their first follow-up visit. The other four patients had significant improvement in pain and were satisfied with the results. Long-term follow-up data were not available for this study.

CONCLUSION

MDSC remains a valuable approach with high success rates and should be considered for PVPS that is refractory to medical therapy. MDSC appears to have the most success for patients who experience a temporary relief from a cord block and can significantly improve the patient's quality of life and ability to return to daily activities. Tan WP, Levine LA. Micro-Denervation of the Spermatic Cord for Post-Vasectomy Pain Management. Sex Med Rev 2018;6:328-334.

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.

Chronic scrotal pain and microsurgical spermatic cord denervation: tricks of the trade

Every practicing urologist encounters patients complaining of chronic scrotal content pain (CSCP). This condition can be equally frustrating for both patients and clinicians as there are no clear treatment guidelines, or pathways, for urologists to follow. As a result, most patients typically seek out multiple providers without improvements in their symptoms. Fortunately, microsurgical spermatic cord denervation (MSCD) is becoming an accepted, reliable and reproducible technique for definitively addressing CSCP in select patients. This manuscript reviews the background, effectiveness and current practice guidelines for scrotal pain in general, and MSCD in particular. Technical insights into how this technique can be performed both safely, and efficaciously, are provided. Finally, the manuscript presents a simple, yet detailed, easy to follow treatment algorithm to aid all urologists in the management of patients presenting with chronic pain.

A review of varicocele repair for pain

A dilation of the pampiniform venous plexus in the scrotum above the testicle, called a varicocele, affects approximately 15% of the general male population. While the majority is asymptomatic, pain results in up to 10% of cases of varicoceles. The pain associated with varicoceles is typically mild and is described as heavy, achy, or dull—and is usually isolated to the testicle or spermatic cord. Guidelines clearly recommend varicocele repair in males with varicoceles, infertility, and an abnormal semen analysis. While chronic, severe pain is an additional indication for repair, a careful evaluation to rule out other etiologies in addition to a period of conservative management are necessary prior to surgical treatment because of the high incidental prevalence of varicoceles in the general population. Several techniques for varicocele repair have been described, including retroperitoneal, laparoscopic, inguinal, and subinguinal. Additionally, recent adjuncts to improve visualization and identification of critical structures including the operating microscope and microvascular Doppler ultrasound have improved success and complication rates. With careful patient selection, outcomes of varicocele repair with regard to pain are excellent, with over 90% of patients experiencing symptomatic relief. After failure of conservative treatments, a varicocele associated with pain should be considered for repair, and the microsurgical subinguinal approach is the gold standard surgical treatment, offering excellent outcomes while minimizing risk of complications.

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.