OnabotulinumtoxinA (Botox) nerve blocks provide durable pain relief for men with chronic scrotal pain: a pilot open-label trial

Evaluation of Botox treatment in patients with chronic scrotal pain: Protocol for a randomized double-blinded control trial

Background

Chronic scrotal pain is a common condition with a prevalence of 2.5-4.8% in male outpatients. Up to 40% of these patients report depressive symptoms and many feel isolated. Minimal invasive treatment is lacking, while spermatic cord injections of Botox® (BTX) have been proposed to offer long-term pain relief.

Study Design

This research protocol comprises a prospective multicentre, randomized, double-blinded clinical trial drawing patients from other urological departments in the region of Southern Denmark.

End Points

The primary end point will be reduction in pain evaluated by visual analogue score for pain at 3 months. Secondary end point will be length of effect of BTX injections along with changes in quality of life.

Patients and Methods

The study will include 50 patients for randomization to either spermatic cord block with 100 IE BTX or sterile saline. All patients will prior to randomization undergo physical examination and will be asked to fulfil multiple questionnaires regarding pain and impact in daily life, that is, (1) visual analogue score for pain, (2) quality of life (EQ-5D-5L), (3) Chronic Prostatitis Symptom Index (NIH-CPSI), (4) ICD-10 depression questionnaire (MDI), (5) Likert global assessment scale, and (6) International Index of Erectile Function questionnaire. Physical examination and fulfilment of the questionnaires will be repeated multiple times throughout the study period of 12 weeks. After this time point, patients will be unblinded, and the control arm will be given the opportunity of cross-over.

Cryoablation of the penile nerves for chronic penile pain

We present a unique case of a 39-year-old male with a 20-year history of chronic penile pain. Unfortunately, there are currently very limited reports on how best to manage chronic penile pain, as chronic penile pain is a diagnosis of exclusion without any apparent disease. Here, we describe our patient's clinical presentation of chronic penile pain, history of previously failed medical and procedural treatments, and eventually completion of cryoablation of the penile nerves. In this case study, we demonstrated that targeted cryoablation of the penile nerves is a potential treatment option for chronic penile pain that failed medical management. We also discuss the anatomy and innervation of the penis as it relates to sensation of chronic penile pain and subsequent cryoablation of the penile nerves.

Gold Standard Care of Chronic Scrotal Pain

INTRODUCTION

Chronic scrotal pain (CSP) can be a debilitating condition for patients and is often difficult to characterize.

METHODS

A review of literature was performed using Embase, Cochrane and Medline databases in the period 1.January 2010 to 1.January 2021. We found 132 articles, and the authors screened abstract and references. Thirty-seven articles are included after removing duplicates.

RESULTS

This review presents a variety of medical and surgical treatment options for CSP such as spermatic cord blocks (36-80% success rate), microsurgical denervation of the spermatic cord (76-100% success rates), Botox (56% success rate), targeted ilioinguinal and iliohypogastric peripheral nerve stimulation, and radical orchiectomy (55-75% success rate).

CONCLUSION

An overview of various treatment options, both non-surgical and surgical are provided, with the aim of establishing what may be the best treatment option for CSP.

Efficacy and Safety of Ningmitai Capsules in Patients with Chronic Epididymitis: A Prospective, Parallel Randomized Controlled Clinical Trial

OBJECTIVES

To evaluate the efficacy and safety of Ningmitai (NMT) capsules in patients with chronic epididymitis.

METHODS

This prospective randomized controlled trial included 112 patients diagnosed with chronic epididymitis. The patients were randomized (1 : 1 : 1) to receive levofloxacin (LVX), NMT, or NMT combined with LVX for 4 weeks. The patients were followed up at 2 and 4 weeks after initiation of treatment and were evaluated in terms of Chronic Epididymitis Symptom Index (CESI) scores, epididymal nodules, and safety parameters. The primary endpoints were the CESI scores at the end of 2 and 4 weeks of treatment. The secondary endpoints included the mean epididymal nodule diameter and the clinical efficacy rate. Safety was evaluated by hepatorenal function tests and adverse event reports during the trial.

RESULTS

After 2 weeks of treatment, the CESI score of the NMT group was significantly lower than that of the LVX group (P < 0.05). In addition, the clinical efficacy rate of the NMT group was significantly higher than that of the LVX group (55% vs. 8.33%, P < 0.0001), indicating that NMT has a rapid effect on chronic epididymitis. After 4 weeks of treatment, there was no significant difference in CESI scores or clinical efficacy rates between the two monotherapy regimens (P > 0.05); however, the mean diameter of epididymal nodules was significantly smaller in the NMT group than in the LVX group (P < 0.0001). Moreover, after 4 weeks of treatment, the patients in the LVX + NMT group, which had a clinical efficacy rate of 97.22%, had lower CESI scores (both P < 0.01) and a smaller epididymal nodule diameter (vs. LVX, P < 0.0001; vs. NMT, P < 0.05) than those in the other two groups. No adverse events or abnormal hepatorenal function were found during the study.

CONCLUSION

NMT significantly improved CESI scores and epididymal nodule diameter in patients with chronic epididymitis. The combination of NMT and LVX provides a much better effect than monotherapy, and this treatment regimen was well tolerated.

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.

Intrascrotal injection of botulinum toxin A, a male genital aesthetic demand: Technique and limits

INTRODUCTION

Scrotal rejuvenation is a real male aesthetic demand. Scrotal injection of botulinum toxin makes the testicles smoother, less dangling and subjectively larger.

METHODS

Intrascrotal botulinum toxin injections were performed to a 44-year-old patient for aesthetic purposes. We used the intracremasteric injection protocol. Cremaster muscle injections and dartos muscle injections were performed.

RESULTS

The patient was satisfied. No adverse reaction to the intrascrotal botulinum toxin injection was observed. The patient wanted to repeat the procedure in the future.

CONCLUSION

At the moment, there is no recommendation about the aesthetic use of intrascrotal injections of botulinum toxin A and the risks are unknown. The purpose of this article is to show the feasibility, context and technical modalities of intrascrotal injection. The risk of infertility is real, but marginal for men who no longer have progeny's desire.

LEVEL OF EVIDENCE

Level 3.

Canadian Urological Association best practice report on chronic scrotal pain

N/A

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.

Frequency and severity of chronic scrotal pain in Canadian men presenting to urologists for infertility investigations

Background

Chronic scrotal pain (CSP) may be debilitating in men presenting for treatment for CSP, but we have little information on the frequency and severity of CSP in the men who do not seek care for the CSP. Our objective was to identify the frequency and characteristics of CSP in a population of men presenting for reasons other than CSP to a urology clinic.

Methods

Men presenting to a urology clinic for investigation of male infertility (INF) completed a standardized CSP questionnaires if they self-reported having CSP. This prospectively collected database was then retrospectively analyzed.

Results

Forty-five of 1,203 (3.7%) of INF patients (mean age 35: range, 24–59), reported having CSP (INF/CSP). Our comparison group was 131 men presenting for investigation of CSP [mean age 43¡À12 (SD) years with a mean duration of CSP of 4.7¡À5.95 years]. On average, men with INF/CSP had less severe and frequent pain than those with CSP, with significantly less pain during “bad” pain episodes (5.2¡À2.2 vs. 7.4¡À2.1, VAS score 0–10, P<0.0001 Student’s t-test), less frequent “bad” pain episodes (23%¡À21% vs. 42%¡À30% of the time, P<0.0001 Student’s t-test) and lower proportion of men who reported having severe pain (VAS score 7–10/10) (4/45 vs. 46/131, P<0.001, chi-squared test). Both groups reported a negative impact of the pain on quality of life (QOL), with 60% and 86% of men with INF/CSP and CSP alone reporting that they would feel ‘mostly dissatisfied’, ‘unhappy’, or ‘terrible’ if they had to continue life with their present scrotal pain symptoms.

Conclusions

Clinicians should be aware that CSP is common among men presenting for conditions other than CSP and that even if the pain levels are not “severe”, the chronic pain often has a significant negative impact on QOL.