Chronic testicular pain: an overview

Chronic testicular pain (orchialgia, orchidynia or chronic scrotal pain) is common and well recognized but its pathophysiology is poorly understood. Currently treatment is largely empirical. This article aims to present an overview of its prevalence, possible aetiology and the available treatment options. The contribution of psychological factors is unclear, although some of these patients undoubtedly are depressed. Post vasectomy chronic testicular pain may be due to functional obstruction of the vas, or to spermatic granuloma. The surgical technique used may be relevant and the application of intraoperative local anaesthetic may have a role in reducing the risk. The importance of the sympathetic nervous system and the role of a possible alteration of the adrenergic receptors of the vas deferens in patients with chronic testicular pain are discussed. For patients failing to respond to conservative treatment, microsurgical denervation of the spermatic cord, epididymectomy and vasovasostomy have all shown a degree of relief. Unfortunately a small number of patients fail to respond to both conservative and more invasive treatment methods and for them the only available therapeutic option is inguinal orchiectomy.     

Microsurgical subinguinal cremaster muscle release for chronic orchialgia secondary to hyperactive cremaster muscle reflex in adults

A careful history and evaluation of men with chronic orchialgia elucidates the aetiology in some men to be a hyperactive cremaster muscle reflex with testicular retraction as the cause. The objective is to evaluate outcomes in men who underwent microsurgical subinguinal cremaster muscle release (MSCMR) with a retrospective chart review between September 2011 and April 2019. Nineteen men with hyperactive cremaster muscle reflex in 25 spermatic cord units underwent MSCMR, six bilateral and thirteen unilateral. Candidacy for MSCMR included answering yes to the question: “at times of testicular pain, does the testicle retract up in the groin to the extent that you have to milk it back down to the scrotum?”, normal digital rectal examinations, negative urinalyses, negative scrotal Doppler ultrasounds, vigorous retraction of testis with Valsalva on examination and pain without an anatomic or pathologically identifiable aetiology except testicular retraction. Of the men who underwent MSCMR, 100% (25/25) of spermatic cord units had resolution of testicular retraction and 92% (23/25) of spermatic cord units had complete resolution of orchialgia. There was one complication, a small scrotal hematoma which resolved. MSCMR is an effective option for men with orchialgia secondary to testicular retraction due to a hyperactive cremaster muscle reflex.     

MANAGEMENT OF CHRONIC ORCHIALGIA OF UNKNOWN ETIOLOGY

The treatment of patients with chronic unilateral or bilateral orchialgia, defined as intermittent or constant testicular pain of greater than 3 months and of unclear cause, is difficult. This pain significantly interferes with the daily activities of the patient. We have seen 12 patients with chronic orchialgia of unknown etiology and each had a normal history, physical examination and normal scrotal sonogram. Three patients were treated with nonsteroidal anti-inflammatory drugs and obtained partial pain relief. Three patients underwent spermatic cord nerve blockade using a combination of 1% lidocaine and 40 mg methylprednisolone and experienced partial pain relief. Four patients underwent inguinal orchiectomy after failing conservative management: three reported complete relief of pain, and the other partial relief. Two patients had bilateral transrectal injections of local anesthetic (5 ml bupivacaine) and methylprednisolone into the region of the pelvic plexus under transrectal ultrasound guidance. They were successfully treated with this injection technique. On the basis of our results, we recommend transrectal blockade of nerves from the pelvic plexus or inguinal orchiectomy as the procedure of choice for patients in whom medical treatment fails.     

精索显微去神经术治疗慢性睾丸痛1例报告并文献复习

目的：探讨慢性睾丸痛（CTP）的临床特点和诊治方法。方法：报告1例CTP患者的临床资料,患者输精管结扎术后多年双侧CTP,左侧附睾切除后仍无缓解。术前疼痛视觉模拟评分（VAS）：左侧睾丸疼痛8分,右侧4分。人院后接受左侧精索显微去神经术（MDSC）＋右侧输精管再通术。结果：术后随访1年VAS评分：左侧睾丸疼痛2分,右侧0分,患者恢复正常生活工作。结论：MDSC通过切断髂腹股沟神经和精索内相关神经,来阻断睾丸疼痛信号的传导,在特发性或难治性CTP的治疗中值得推荐。     

Ipsilateral orchialgia after laparoscopic donor nephrectomy

BACKGROUND AND PURPOSE: Complications related to laparoscopic donor nephrectomy (LDN) have been similar to those associated with open renal donor nephrectomy (ODN). However, during clinical follow-up, we noted a group of male patients who developed acute ipsilateral orchialgia after LDN. In an effort to assess the incidence of this problem, determine the etiology, and adapt preventive measures, we reviewed our experience. PATIENTS AND METHODS: A retrospective chart review was performed on 381 consecutive LDNs performed between February 1995 and November 2001 to assess for postoperative orchialgia. There were 157 male patients (41.2%) in our series. Our technique involves ligation of the gonadal vessels, periureteral tissue, and ureter over the iliac artery using either surgical clips or a linear laparoscopic GIA stapler. RESULTS: Left-sided nephrectomy was performed in 145 (92.3%) male patients, of whom 14 (9.6%) complained of ipsilateral orchialgia. Statistical analysis (t-test) of the orchialgia and non-orchialgia groups with respect to operative time, estimated blood loss, warm ischemia time, and ureteral length revealed no statistical differences (P>0.1). Onset of testicular pain occurred on average at postoperative day 5 (range days 1-14). The mean follow-up was 24.4 +/- 14.8 months (range 6-52 months). Ten patients were evaluated with transcrotal duplex ultrasonography. One patient with decreased flow and was managed conservatively, while one patient without detectable testicular flow underwent surgical exploration. One patient underwent spermatocelectomy and had improvement but not resolution of pain. The remaining patients were treated conservatively with nonsteroidal anti-inflammatory medication and empiric antibiotics. Seven patients (50%) had complete spontaneous resolution of orchialgia on average 6.3+/-7.2 months after LDN. CONCLUSION: Laparoscopic donor nephrectomy has proven to be an effective and safe surgical procedure. However, further evaluation has demonstrated a complication not previously reported, namely ipsilateral orchialgia. The etiology remains unclear but may be injury to the sensory nerves of the testicle during dissection of the periureteral tissue or transection of the spermatic cord. Further anatomic and physiological studies are needed to elucidate the pathophysiology of this problem.     

Die mikrochirurgische testikuläre Samenstrangdenervierung als Therapie der chronischen Testalgie

Diagnosis and treatment of chronic testicular pain (CTP) has been a difficult and often unrewarding clinical situation. Success rates of conservative and surgical measures rarely exceed 55% to 73% and 10% to 40%, respectively. We report on our experience with microsurgical testicular denervation as therapeutic option in CTP. Following an extensive preoperative work-up and a positive response to spermatic cord block, 25 patients underwent microsurgical testicular denervation. After a mean follow-up of 31.5 months 24/25 patients are painfree; no intra- or postoperative complications were encountered. In none of the cases testicular atrophy or testicular hydrocele was observed during postoperative follow-up. Microsurgical testicular denervation produces reliable and reproducible excellent therapeutic success rates and should be integrated in the management of CTP at an early stage. High success rates, however, require adequate and meticulous diagnostic workup of the patients with the spermatic cord block using saline and different local anaesthetics being an initial diagnostic armentarium predicting postoperative outcome.     

Management of chronic testalgia by microsurgical testicular denervation

OBJECTIVES: Chronic testicular pain (CTP) is defined as uni- or bilateral, intermittent or continuous testicular discomfort of at least 3 months duration that interferes with the patient's daily activities and prompts him to seek medical advice is a rather common urological manifestation of chronic pain syndrome. Diagnosis and treatment of CTP has been a difficult and often unrewarding clinical situation. Success rates of conservative and surgical measures including epididymectomy and orchiectomy rarely exceed 55-73% and 10-40%, respectively. We report our experience on microsurgical testicular denervation as therapeutic option in CTP. PATIENTS AND METHODS: Following an extensive preoperative work-up (urine/semen cultures, transrectal ultrasound, testicular sonography, pain and orthopedic consultation) not revealing any pathologic abnormalities and a positive response to spermatic cord block, 35 patients underwent microsurgical testicular denervation. In brief, spermatic cord was dissected, vas deferens, cremasteric muscle and testicular vessels were separated. After identification of the testicular artery by application of vasodilatating agents using magnifying loops or the operating microscope, all structures besides the testicular artery, vas deferens and 1-2 lymphatic vessels were coagulated and transsected using bipolar diathermy. RESULTS: After a mean follow-up of 31.5 months 34/35 (96%) patients are completely pain-free; no intra- or postoperative complications were encountered. No case of testicular atrophy or hydrocele formation was observed during postoperative follow-up. CONCLUSIONS: Microsurgical testicular denervation results in reliable and reproducible excellent therapeutic success rates of 96% and should be integrated in the management of CTP at an early stage. High success rates require adequate and meticulous diagnostic work-up of the patients by spermatic cord block using saline as placebo and different local anaesthetics as an initial therapeutic armentarium predicting postoperative outcome.     

Clinical study on acute scrotum]

Between April 1986 and July 1990, we experienced 13 cases of acute scrotum with surgical exploration. Six of the patients had torsion of the spermatic cord; three had torsion of an appendix of the epididymis, one had torsion of a testicular appendix, one had testicular rupture, one had acute epididymitis and one was normal. Their ages ranged from 3 months to 55 years (mean: 17.7 years), and the patients with torsion of the spermatic cord ranged from 5 to 25 years in age (mean: 16.3 years). No specific symptoms, signs, or laboratory findings were noted in patients with torsion of the spermatic cord. In the majority of cases, scrotal swelling and redness of the scrotal skin were present, and we could not distinguish parts of the scrotal contents. From 2 to 92 hours had passed before the patients presented, and patients who first attended other clinics tended to be treated in an inappropriate manner. Orchidopexy was performed in all patients with torsion of the spermatic cord. At present, only one testis which was treated after a delay of 92 hours has proven to be atrophic. Early consultation of a urological clinic and early surgical exploration are important in the treatment of the acute scrotum.     

Torsion of the spermatic cord and testicular annexes

Torsion of the spermatic cord is responsible for an ischemic necrosis of the testis in the absence of rapid resaturation of the perfusion. It is also responsible for contralateral parenchymal alterations resulting in subfertility. Torsion of the spermatic cord mostly occurs in newborns and adolescents. Its classical clinical pattern is that of an acute-onset ipsilateral scrotal pain. Its diagnosis is clinical and its suspicion must lead to an immediate surgical scrotal exploration. The surgical procedure may be preceded by an attempt of external detorsion, but never delayed by any para clinical exploration. If the diagnosis is confirmed at surgery, contra-lateral orchidopexy must be considered. Trophicity of the ischemic testicle and the fertility of the patient are uncertain. Improvement of the prognosis of patients with torsion of the spermatic cord needs an urgent surgical management of the patients. It also claims for the development of testicular parenchyma protective medical treatments. But the most important improvement should come from parental and teenagers educational information so that they urgently visit a practitioner in case of acute scrotal pain.     

迷你腹腔镜治疗隐睾合并同侧腹股沟疝的临床研究

目的探讨迷你腹腔镜治疗隐睾合并腹股沟疝的安全性和有效性。 方法收集2010年10月至2018年10月于河北省肃宁县人民医院泌尿外科收治的21例隐睾合并同侧腹股沟疝患者。应用迷你腹腔镜（5.0 mm直径高清晰腹腔镜,2.8 mm的分离钳,持针器等）行微创治疗。对本研究患者进行回顾性分析。 结果本组患者平均手术时间（95.0±12.3）min。因隐睾、精索发育不良,行阴睾切除疝囊高于结扎2例。6例患儿因分离精索、输精管时后腹膜缺损,内环口后腹膜未关闭。3例成人患者完成隐睾松解固定术后,内环口过大,遂将5.0 mm Trocar更换为10 mm Trocar。置入补片,缝合后腹膜。21例患者术后无阴囊血肿、阴囊感染、切口感染等并发症。术后无慢性腹股沟痛。2例术后分别为5.5年和1.7年一直睾丸较小,超声示睾丸萎缩。随访（6.6±3.4）年（0.3～8.7年）,无疝复发。 结论应用迷你腹腔镜治疗隐睾合并腹股沟疝是安全可靠的,损伤小、恢复快、并发症少。     

Microsurgical denervation of the rat spermatic cord and its connection to the diagnosis and treatment of chronic orchialgia: a bench to bedside experience

Chronic orchialgia is a common urologic problem, however, determination of the etiology is often difficult and the pathophysiology is poorly understood. As a result, there is no clear algorithm for surgical treatment for men who have failed conservative medical treatment. This review aims to describe microsurgical denervation of the rat spermatic cord (SC) and summarize several surgical techniques that have been described in the literature ranging from orchiectomy to epididymectomy to vasectomy reversal for post-vasectomy orchialgia. More recent studies advocate for microsurgical denervation of the spermatic cord (MDSC), which can be performed with a standard operating microscope or laparoscopic/robotic techniques providing optical magnification. Data regarding efficacy and complications for all surgical treatments is outlined. Experimental modalities, such as the use of multiphoton microscopy (MPM) to identify and ablate nerves surrounding the vas deferens are also described. Finally, given the fact that chronic orchialgia often affects young men, we summarize safety data generated from an animal model regarding the effect of microsurgical denervation on the structure and function of the testis and vas deferens.     

Two cases of testicular infarction: the usefulness of enhanced MRI for preoperative diagnosis]

The differential diagnosis in acute scrotum, particularly torsion of spermatic cord and epididymitis, is sometimes difficult. An erroneous diagnosis may result in unnecessary and improper treatment. We report two cases of testicular infarction including torsion of spermatic cord, preoperatively diagnosed by enhanced magnetic resonance imaging (MRI). Case 1: A 16-year-old boy presented with a 3-day history of left scrotal swelling and left lower abdominal pain. He had fever and leukocytosis. Antibiotics for 2 days failed to relieve the symptoms. Enhanced MRI showed absence of blood flow in the left testis. Scrotal exploration revealed hemorrhage and necrosis in the left testis. Left orchiectomy and right orchiopexy were performed. Case 2: A 12-year-old boy visited with scrotal swelling and fever 30 hours after an acute onset of left scrotal pain. Enhanced MRI showed absence of blood flow in the left testis. Exploration revealed left necrotic testis with torsion of spermatic cord. Left orchiectomy and right orchiopexy were performed. Our two cases suggested that enhanced MRI, by which the intratesticular blood flow can be evaluated, may be useful for the diagnosis of testicular infarction.     

Torsion of spermatic cord and testicular appendages

Forty-seven cases of torsion of the spermatic cord and testicular appendages have been reviewed. Twenty-eight patients with acute spermatic cord torsions underwent surgical correction. Only 10 were treated in time to preserve viability. The other cases were either gangrenous and required orchidectomy or were questionably viable. Acute, painful scrotal swelling with negative findings on urinalysis is a surgical emergency. Ten patients had warning attacks, but because of delay in diagnosis and treatment, 4 required orchidectomy. Those patients with spermatic cord torsion who were detorsed before twelve hours had elapsed had viable testes. Patients with complaints of intermittent scrotal swelling and pain, with negative urinalysis, may be suffering from intermittent spermatic cord torsion and should be evaluated for prophylactic orchidopexy; 7 patients were treated in this manner. Six of these had a transverse lie of both testes, which suggested the underlying anatomic defect leading to torsion of the spermatic cord. The diagnosis of epididymitis or epididymo-orchitis is untenable with a negative finding on urinalysis and results in delay in correct diagnosis and treatment.     

Orchialgia and the chronic pelvic pain syndrome

This review paper highlights the important health issue of orchialgia and the chronic pelvic pain syndrome. There are a number of specific and non-specific etiologies and different treatment options based on the sub-categorization of orchialgia. The focus of this article is on the specific etiologies of chronic orchialgia as well as non-specific scrotal pain, and the diagnostic evaluation and optimal management of these men. The clinician must be cautious about assuming that orchialgia is constitutive in the chronic pelvic pain syndrome, and must be diligent in ruling out specific etiologies for scrotal pain prior to managing orchialgia as a non-specific chronic pain syndrome.     

Analysis and management of chronic testicular pain

A total of 45 patients was seen in consultation between May 1980 and April 1989 for chronic unilateral or bilateral orchialgia, defined as intermittent or constant testicular pain 3 months or longer in duration that significantly interferes with the daily activities of the patient so as to prompt him to seek medical attention. We analyzed 34 patients available for followup in terms of socioeconomic parameters, etiology and duration of pain, associated urological symptomatology, specific treatment and results of therapy. Of the patients 31 underwent surgical treatment after failing medical management (24 orchiectomies, 10 epididymectomies, 5 orchiopexies and 1 hydrocelectomy). Of 10 patients who underwent epididymectomy 9 underwent subsequent orchiectomy as definitive treatment. Of 15 patients who underwent inguinal orchiectomy 11 (73%) reported complete relief of pain, while 4 had partial relief. Of the 9 patients who underwent scrotal orchiectomy 5 (55%) reported complete relief of pain, 3 had partial relief and 1 denied improvement. On the basis of these results we recommend inguinal orchiectomy as the procedure of choice for the management of chronic testicular pain when conservative measures are unsuccessful.     

Pulsed radiofrequency as a treatment for groin pain and orchialgia

Inguinal and testicular pain are challenging problems for which no reliable, standardized treatment exists. We report 3 patients with groin pain or orchialgia who were treated with pulsed radiofrequency of the nerves innervating these areas. All 3 patients reported complete pain relief at their 6-month follow-up visits. The techniques and settings used for the nerve blocks and radiofrequency procedures are explained in detail, along with a brief synopsis of the rationale for using it. Randomized, placebo-controlled studies are needed to better assess the efficacy of this procedure and identify eligible candidates.     

Chronic orchialgia in the pain prone patient: the clinical perspective

Chronic pain syndromes are well known to the medical community. The incidence of chronic pain syndromes and cost of evaluating these patients are rapidly increasing. Chronic testicular pain is a fairly common manifestation of a chronic pain syndrome. Retrospectively, we reviewed the records of 48 patients with chronic testicular or scrotal pain (greater than 6 months) evaluated at our institution during the last 7 years. These patients had multiple diagnostic and interventional procedures with few positive findings. There was little improvement in these patients after multiple surgical procedures. Based on the paucity of objective clinical findings a carefully directed diagnostic evaluation for orchialgia is outlined. The treatment of these patients is best managed by a multidisciplinary approach involving the urologist and a pain clinic environment. We believe that extensive diagnostic testing is not indicated in the absence of clinical findings and may serve to worsen the condition or lead to iatrogenic injury. Surgical intervention should be limited to cases when a clear indication is present.     

Necrotic testicle with increased blood flow on doppler ultrasonic examination

A twelve-year-old male with a five-day history of scrotal swelling and pain had increased blood flow on ultrasonic examination. A testicular flow and scan indicated an ischemic testicle. Surgical exploration revealed complete torsion of the spermatic cord. In chronic cases of torsion, the Doppler stethoscope may give a false negative result because of reactive hyperemia.     

Testicular fixation in adult retractile testis: technical notes

A variety of techniques for scrotal orchiopexy have been described in the literature, including those without suture fixation, such as the scrotal pouch. We perform a simple modified technique for bilateral testicular fixation in patients with bilateral and/or unilateral adult retractile testis and with symptoms characterised by chronic orchialgia due to testicular hypermobility or repeated funicular subtorsion.     

The impact of internal spermatic artery ligation during laparoscopic varicocelectomy on recurrence rate and short post operative outcome

OBJECTIVE: To prospectively compare the recurrence rate and short postoperative outcome after randomized laparoscopic varix ligation with internal spermatic artery (ISA) preservation versus laparoscopic varix ligation with ISA ligation. MATERIAL AND METHODS: Twenty-five patients with 35 varicocele who required varix ligation for infertility in 13 patients, scrotal pain in 15 patients and scrotal swelling in 2 patients who underwent one of two procedures: laparoscopic varix ligation with ISA prservation (Group A) or laparoscopic varix ligation with ISA ligation (Group B) were postoperatively evaluated for short post operative outcome and underwent percutaneous spermatic venograms to detect recurrence. Fisher's Exact Test was used for statistical analysis. RESULTS: Recurrence through parallel collaterals was noted in 39% and 5.9% in Group A and Group B respectively as demonstrated on percutaneous spermatic venous venography (PSV) (statistically significant p = 0.0408). Preoperative pain completely resolved in all patients in Group B and persisted in 45% in Group A. However, this was not statistically significant (p = 0.088). No testicular atrophy or hydrocele formation was noted in either group. CONCLUSIONS: Laparoscopic varix ligation with ISA ligation has lower recurrence rate than laparoscopic varix ligation without ISA ligation and may provide better varicocele related pain control with no increase in hydrocele or testicular atrophy rate. We recommend ISA ligation routinely during laparoscopic varix ligation.