Chronic testicular pain is a common malady causing havoc in men with this problem. The pain can be so debilitating that men lose productivity in the work place, have sexual problems and even depression that requires treatment. Men often have anxiety about cancer. Chronic testicular pain is also called orchialgia, orchidynia, chronic pelvic pain syndrome, or chronic scrotal pain syndrome. These are all terms used to describe intermittent or constant testicular pain.
Chronic testicular pain occurs at any age but the majority of the patients are in their mid to late thirties. The pain can involve one or both testicles. The pain can remain localized in the scrotum or radiate to the groin, perineum, back or legs. On clinical examination the testis may be tender but in the majority of men is otherwise unremarkable.
Causes of orchialgia include infection, tumor, testicular torsion, varicocele, hydrocele, spermatocele, trauma and previous surgical procedures such as a vasectomy.
Any organ that shares the same nerve pathway with the scrotal contents can present with pain in this region. Pain arising in the kidney, hip, prostate gland or back pain caused by a herniated disc can present as testicular pain. Injury to nerves following a hernia repair can cause chronic testicular pain. Chronic testicular pain has been recognized as a feature of diabetic. Some men attribute the start of their chronic testicular pain to some form of blunt injury to the testicles. Unfortunately in a large proportion of patients the cause of their pain remains unknown.
Post vasectomy chronic pain syndrome
It is not common but there is a possibility that following a vasectomy an obstruction or congestion of the vas or in the epididymis may be the cause of the pain.
If the man has an injection of local anesthetic, such as xylocaine, prior to cutting the vas, this may reduce both immediate and long term post vasectomy pain.
The formation of spermatic granuloma following a vasectomy has been well documented but its protective or causative role as been controversial.
Scrotal ultrasonography is usually part of the evaluation of patients with scrotal pain. However, in the absence of significant clinical findings during physical examination and in the presence of negative urinalysis, the only real benefit of scrotal ultrasound is reassurance to the patient worried about cancer
Surgery is to be avoided if possible. Even if infection has not been identified a small number of patients may respond to a combination of antibiotics and non-steroidal anti-inflammatory drugs. Tricyclic antidepressants, such as imipramine, sometimes relieve the pain. Those with intractable symptoms may benefit from a multidisciplinary team approach involving a urologist and a pain clinic specialist including a psychologist. Transcutaneous electrical stimulation or TENS analgesia often have favorable results. This works on the principle that transcutaneous electrical stimulation causes release of endorphins in the nerves of the spinal cord that supply the scrotum.
A spermatic cord block with a local anesthetic such as xylocaine can be done in the doctor’s office. The procedure, if successful, can be repeated in regular intervals.
For patients who fail to respond to conservative management and wish to avoid the surgical options that are available in treating chronic orchialgia, a trial with an alpha blocker might be an option.
For patients in whom all medical treatments have failed and testicular pain continues to impair their quality of life, surgical intervention may be indicated as a last resort. A number of surgical strategies have been described.
Microsurgical denervation of the spermatic cord may provide relief of chronic testicular pain. Another technique is to divide the ilioinguinal nerve and its branches.
Removal of the epididmymis or epididymectomy should be performed only if the patient had been counselled regarding the likelihood of poor results.
Putting the vas back together or a vas reversal has helped a number of men with chronic testicular pain.
Unfortunately a small number of patients who fail to respond to medical or more invasive treatment will ultimately undergo removal of the entire testicle for pain relief. This procedure must be the last resort.
Chronic testicular pain remains a challenge to doctor as well as the patient.
Help is usually available with medication, nerve stimulation with TENS, and only surgery as a last resort.