World J Mens Health.  2017 Dec;35(3):146-155. 10.5534/wjmh.17047.

What Can We Do for Chronic Scrotal Content Pain?

• Tan WP
• Levine LA

• KMID: 2398563
• DOI: http://doi.org/10.5534/wjmh.17047

Abstract

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.

Keyword

Chronic pain; Epididymis; Epididymitis; Pelvic pain; Vasovasostomy

MeSH Terms

Chronic Pain
Epididymis
Epididymitis
Humans
Male
Pelvic Pain
Vasovasostomy

Figure

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  Fig. 1 Diagnosis and treatment algorithm for chronic scrotal content pain. NSAIDs: non-steroidal anti-inflammatory drugs, CT: computed tomography, MRI: magnetic resonance imaging, A/P: abdomen or pelvis.

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  Fig. 2 Microdenervation of the spermatic cord. (A) Marking of inguinal site. (B) Dissection to expose the spermatic cord. (C) Spermatic cord supported by a Penrose drain with the cord fascia opened. (D) Arteries secured by a vessel loop. (E) After completion of the dissection, only the cremasteric artery, testicular artery, deferential artery, and lymphatics remain (top to bottom).

Reference

1. Davis BE, Noble MJ, Weigel JW, Foret JD, Mebust WK. Analysis and management of chronic testicular pain. J Urol. 1990; 143:936–939.

2. Levine LA, Hoeh MP. Evaluation and management of chronic scrotal content pain. Curr Urol Rep. 2015; 16:36.

3. Christiansen CG, Sandlow JI. Testicular pain following vasectomy: a review of postvasectomy pain syndrome. J Androl. 2003; 24:293–298.

4. Tatem A, Kovac JR. Chronic scrotal pain and microsurgical spermatic cord denervation: tricks of the trade. Transl Androl Urol. 2017; 6:S30–S36.

5. Strebel RT, Leippold T, Luginbuehl T, Muentener M, Praz V, Hauri D. Chronic scrotal pain syndrome: management among urologists in Switzerland. Eur Urol. 2005; 47:812–816.

6. Tan WP, Levine LA. An overview of the management of post-vasectomy pain syndrome. Asian J Androl. 2016; 18:332–337.

7. Tan WP, Levine LA. Micro-denervation of the spermatic cord for post-vasectomy pain management. Sex Med Rev. 2017; DOI: 10.1016/j.sxmr.2017.06.002.

8. Ng CJ, Teo CH, Ho CC, Tan WP, Tan HM. The status of men's health in Asia. Prev Med. 2014; 67:295–302.

9. Parekattil SJ, Cohen MS. Robotic surgery in male infertility and chronic orchialgia. Curr Opin Urol. 2010; 20:75–79.

10. Quallich SA, Arslanian-Engoren C. Chronic testicular pain in adult men: an integrative literature review. Am J Mens Health. 2013; 7:402–413.

11. Patel AP. Anatomy and physiology of chronic scrotal pain. Transl Androl Urol. 2017; 6:S51–S56.

12. Oka S, Shiraishi K, Matsuyama H. Microsurgical anatomy of the spermatic cord and spermatic fascia: distribution of lymphatics, and sensory and autonomic nerves. J Urol. 2016; 195:1841–1847.

13. Calixte N, Brahmbhatt J, Parekattil S. Chronic testicular and groin pain: pathway to relief. Curr Urol Rep. 2017; 18:83.

14. Uçeyler N, Tscharke A, Sommer C. Early cytokine expression in mouse sciatic nerve after chronic constriction nerve injury depends on calpain. Brain Behav Immun. 2007; 21:553–560.

15. Morgan RJ, Parry JR. Scrotal pain. Postgrad Med J. 1987; 63:521–523.

16. Belanger GV, VerLee GT. Diagnosis and surgical management of male pelvic, inguinal, and testicular pain. Surg Clin North Am. 2016; 96:593–613.

17. Levine L. Chronic orchialgia: evaluation and discussion of treatment options. Ther Adv Urol. 2010; 2:209–214.

18. Kumar P, Mehta V, Nargund VH. Clinical management of chronic testicular pain. Urol Int. 2010; 84:125–131.

19. Kashanian JA, Mazur DJ, Hehemann MC, Morrison CD, Oberlin DT, Raup VT, et al. Scrotal ultrasound for pain: low frequency of absolute surgical indications. Urology. 2017; 108:17–21.

20. van Haarst EP, van Andel G, Rijcken TH, Schlatmann TJ, Taconis WK. Value of diagnostic ultrasound in patients with chronic scrotal pain and normal findings on clinical examination. Urology. 1999; 54:1068–1072.

21. Sinclair AM, Miller B, Lee LK. Chronic orchialgia: consider gabapentin or nortriptyline before considering surgery. Int J Urol. 2007; 14:622–625.

22. Gallagher RM. Management of neuropathic pain: translating mechanistic advances and evidence-based research into clinical practice. Clin J Pain. 2006; 22:S2–S8.

23. Jackson KC 2nd, St Onge EL. Antidepressant pharmacotherapy: considerations for the pain clinician. Pain Pract. 2003; 3:135–143.

24. Sansone RA, Sansone LA. Pain, pain, go away: antidepressants and pain management. Psychiatry (Edgmont). 2008; 5:16–19.

25. Backonja M, Beydoun A, Edwards KR, Schwartz SL, Fonseca V, Hes M, et al. Gabapentin for the symptomatic treatment of painful neuropathy in patients with diabetes mellitus: a randomized controlled trial. JAMA. 1998; 280:1831–1836.

26. Rowbotham M, Harden N, Stacey B, Bernstein P, Magnus-Miller L. Gabapentin for the treatment of postherpetic neuralgia: a randomized controlled trial. JAMA. 1998; 280:1837–1842.

27. Rice AS, Maton S. Gabapentin in postherpetic neuralgia: a randomised, double blind, placebo controlled study. Pain. 2001; 94:215–224.

28. Farrell MR, Dugan SA, Levine LA. Physical therapy for chronic scrotal content pain with associated pelvic floor pain on digital rectal exam. Can J Urol. 2016; 23:8546–8550.

29. Terkawi AS, Romdhane K. Ultrasound-guided pulsed radiofrequency ablation of the genital branch of the genitofemoral nerve for treatment of intractable orchalgia. Saudi J Anaesth. 2014; 8:294–298.

30. Misra S, Ward S, Coker C. Pulsed radiofrequency for chronic testicular pain-a preliminary report. Pain Med. 2009; 10:673–678.

31. Devine CJ Jr, Schellhammer PF. The use of microsurgical denervation of the spermatic cord for orchialgia. Trans Am Assoc Genitourin Surg. 1978; 70:149–151.

32. Choa RG, Swami KS. Testicular denervation. A new surgical procedure for intractable testicular pain. Br J Urol. 1992; 70:417–419.

33. Levine LA, Matkov TG, Lubenow TR. Microsurgical denervation of the spermatic cord: a surgical alternative in the treatment of chronic orchialgia. J Urol. 1996; 155:1005–1007.

34. Ahmed I, Rasheed S, White C, Shaikh NA. The incidence of post-vasectomy chronic testicular pain and the role of nerve stripping (denervation) of the spermatic cord in its management. Br J Urol. 1997; 79:269–270.

35. Heidenreich A, Olbert P, Engelmann UH. Management of chronic testalgia by microsurgical testicular denervation. Eur Urol. 2002; 41:392–397.

36. Strom KH, Levine LA. Microsurgical denervation of the spermatic cord for chronic orchialgia: long-term results from a single center. J Urol. 2008; 180:949–953.

37. Oliveira RG, Camara C, Alves Jde M, Coelho RF, Lucon AM, Srougi M. Microsurgical testicular denervation for the treatment of chronic testicular pain initial results. Clinics (Sao Paulo). 2009; 64:393–396.

38. Marconi M, Palma C, Troncoso P, Dell Oro A, Diemer T, Weidner W. Microsurgical spermatic cord denervation as a treatment for chronic scrotal content pain: a multicenter open label trial. J Urol. 2015; 194:1323–1327.

39. Cadeddu JA, Bishoff JT, Chan DY, Moore RG, Kavoussi LR, Jarrett TW. Laparoscopic testicular denervation for chronic orchalgia. J Urol. 1999; 162:733–735. discussion 735-6.

40. Shapiro EI, Silber SJ. Open-ended vasectomy, sperm granuloma, and postvasectomy orchialgia. Fertil Steril. 1979; 32:546–550.

41. Myers SA, Mershon CE, Fuchs EF. Vasectomy reversal for treatment of the post-vasectomy pain syndrome. J Urol. 1997; 157:518–520.

42. Nangia AK, Myles JL, Thomas AJ JR. Vasectomy reversal for the post-vasectomy pain syndrome: a clinical and histological evaluation. J Urol. 2000; 164:1939–1942.

43. Horovitz D, Tjong V, Domes T, Lo K, Grober ED, Jarvi K. Vasectomy reversal provides long-term pain relief for men with the post-vasectomy pain syndrome. J Urol. 2012; 187:613–617.

44. West AF, Leung HY, Powell PH. Epididymectomy is an effective treatment for scrotal pain after vasectomy. BJU Int. 2000; 85:1097–1099.

45. Calleary JG, Masood J, Hill JT. Chronic epididymitis: is epididymectomy a valid surgical treatment? Int J Androl. 2009; 32:468–472.

46. Padmore DE, Norman RW, Millard OH. Analyses of indications for and outcomes of epididymectomy. J Urol. 1996; 156:95–96.

47. Sweeney P, Tan J, Butler MR, McDermott TE, Grainger R, Thornhill JA. Epididymectomy in the management of intrascrotal disease: a critical reappraisal. Br J Urol. 1998; 81:753–755.

48. Chen TF, Ball RY. Epididymectomy for post-vasectomy pain: histological review. Br J Urol. 1991; 68:407–413.

49. Lee JY, Lee TY, Park HY, Choi HY, Yoo TK, Moon HS, et al. Efficacy of epididymectomy in treatment of chronic epididymal pain: a comparison of patients with and without a history of vasectomy. Urology. 2011; 77:177–182.

50. Ducic I, Dellon AL. Testicular pain after inguinal hernia repair: an approach to resection of the genital branch of genitofemoral nerve. J Am Coll Surg. 2004; 198:181–184.

51. Yamamoto M, Hibi H, Katsuno S, Miyake K. Management of chronic orchialgia of unknown etiology. Int J Urol. 1995; 2:47–49.

52. Costabile RA, Hahn M, McLeod DG. Chronic orchialgia in the pain prone patient: the clinical perspective. J Urol. 1991; 146:1571–1574.

53. Laudano MA, Osterberg EC, Sheth S, Ramasamy R, Sterling J, Mukherjee S, et al. Microsurgical denervation of rat spermatic cord: safety and efficacy data. BJU Int. 2014; 113:795–800.

54. Levine LA. Microsurgical denervation of the spermatic cord. J Sex Med. 2008; 5:526–529.

55. Larsen SM, Benson JS, Levine LA. Microdenervation of the spermatic cord for chronic scrotal content pain: single institution review analyzing success rate after prior attempts at surgical correction. J Urol. 2013; 189:554–558.

56. Benson JS, Abern MR, Larsen S, Levine LA. Does a positive response to spermatic cord block predict response to microdenervation of the spermatic cord for chronic scrotal content pain? J Sex Med. 2013; 10:876–882.

57. Sweeney CA, Oades GM, Fraser M, Palmer M. Does surgery have a role in management of chronic intrascrotal pain? Urology. 2008; 71:1099–1102.

58. Granitsiotis P, Kirk D. Chronic testicular pain: an overview. Eur Urol. 2004; 45:430–436.

59. Kavoussi PK, Costabile RA. Orchialgia and the chronic pelvic pain syndrome. World J Urol. 2013; 31:773–778.

60. Chung JH, Moon HS, Choi HY, Jeong TY, Ha US, Han JH, et al. Inhibition of adhesion and fibrosis improves the outcome of epididymectomy as a treatment for chronic epididymitis: a multicenter, randomized controlled, single-blind study. J Urol. 2013; 189:1730–1734.

61. Barone MA, Hutchinson PL, Johnson CH, Hsia J, Wheeler J. Vasectomy in the United States, 2002. J Urol. 2006; 176:232–236. discussion 236.

62. Polackwich AS, Tadros NN, Ostrowski KA, Kent J, Conlin MJ, Hedges JC, et al. Vasectomy reversal for postvasectomy pain syndrome: a study and literature review. Urology. 2015; 86:269–272.

63. Lee JY, Chang JS, Lee SH, Ham WS, Cho HJ, Yoo TK, et al. Efficacy of vasectomy reversal according to patency for the surgical treatment of postvasectomy pain syndrome. Int J Impot Res. 2012; 24:202–205.