Chronic Scrotal / Testicular Pain
Chronic testicular pain (CTP) is defined as persistent or intermittent unilateral or bilateral testicular pain lasting more than three months, significantly limiting daily activities and requiring medical advice.
This condition is frequently seen by urologists and is difficult to treat. There is no standardized treatment as there is no widely accepted treatment algorithm and care. There are 100,000 cases of chronic testicular pain each year in the United States. Chronic testicular pain is one of the most common reasons for medical discharge from the U.S. military. In most cases, the cause of the pain cannot be found (up to 50%), while residual pain is due to a previous infection or trauma [1,5]. Post-vasectomy pain syndrome has been documented in up to 19% of men who have had a vasectomy.
There are several medical and surgical treatments recommended in the published literature for CTP.
Patient Assessment
A detailed history is important in the evaluation of the patient, including the relevant medical, sexual, and surgical history. At this stage, it is important to rule out non-scrotal factors (eg, distal ureteral calculi) causing pain from musculoskeletal or intra-abdominal pathology.
In addition to the abdominal examination, a physical examination of the groin and genital organs is performed. The scrotal examination can identify the painful area and a digital rectal examination is performed to assess the pelvic floor and prostate. It is important to evaluate the scrotal examination in both supine and standing positions, especially if there are findings suggestive of varicocele or hyperactive Cremaster muscle, in the case of standing retraction of the testis.
“Given the multiple etiological factors contributing to this and the lack of a standardized, widely accepted treatment algorithm and care, this is often frustrating for urologists and patients alike.”
Urinalysis and ultrasound examination of the testicles are the first-line examinations. Depending on the clinical suspicion of the source of pain, abdominal CT examination and spinal MRI are also considered. Increased intravesical pressure may also be associated with testicular pain.
Differential diagnosis
These include chronic epididymitis, post-vasectomy pain syndrome, intermittent torsion, hyperactive cremaster muscle, pain secondary to varicocele and interstitial cystitis, chronic prostatitis, distal ureteral calculi, and intervertebral disc prolapse.
Surgical Management
Failed medical treatment with analgesia and a surgically motivated patient agrees to surgical intervention. Almost all patients use very strong analgesics such as pregabalin, gabapentin, amitriptyline before administration. Use cord block (local anesthetic + steroids) with varying results before recommending cord stripping.
