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Home , Testicular pain, Testicular torsion

Joel J. Heidelbaugh, MD, FAAFP; Mikel Llanes, MD; An algorithm for the treatment William J. Weadock, MD Departments of Family of chronic Medicine (Drs. Heidelbaugh and Llanes), Exhaust conservative medical therapy prior to (Dr. Heidelbaugh), and Radiology (Dr. Weadock), considering surgical options, using this algorithm University of Michigan Medical School, as your guide. Ann Arbor [email protected]

The authors reported no potential confl ict of interest CASE 1  Vincent B, a 33-year-old executive, visits his family relevant to this article. PRACTICE physician for an evaluation of chronic orchialgia. Although his RECOMMENDATIONS testicular pain has waxed and waned for several years, it has › Order ultrasound of the recently worsened, making it increasingly diffi cult for him to and testes to evaluate exercise or to sit for extended periods of time. In fact, this visit chronic testicular pain, with was prompted by a lengthy meeting during which he devel- color Doppler to identify oped a “dull ache” that did not let up until he left the meeting areas of hypervascularity. C and walked around. › Treat suspected epididy- mitis with empiric coverage CASE 2  Jason H, a 42-year-old married father of 3 who had for with either a a 2 years ago, has had progressively worsening tes- 10-day regimen of doxycy- ticular pain ever since. He also has occasional pain after ejacu- TESTICULAR cline (100 mg twice daily) or a lation, but no known . Recently, the pain has PAIN single dose (1 g) of azithromy- TREATMENT cin; treat suspected become so bad that it limits both his physical and sexual activi- TIPS with a single intramuscular ties and is having a negative effect on his relationship with his JOEL J. HEIDELBAUGH, injection (125 mg) of wife. Jason is sexually monogamous, has no signifi cant medi- MD, FAAFP ceftriaxone. A cal history, and takes no prescription medications. › Do not treat small epididy- These 2 cases are based on actual patients we have seen in mal cysts that do not correlate our practices. If Vincent and Jason (not their real names) were with testicular pain; larger, your patients, how would you initiate a work-up for testicular painful cysts can be aspirated, pain? What treatments would you offer? And at what point injected with a sclerosing would you consider a referral to a urologist? agent, or surgically excised. C › Consider surgical options hronic orchialgia is a complex urogenital focal pain only after medical and syndrome in which neurogenic infl ammation is the conservative therapies have C principal mediator. Th is debilitating condition is as- failed to alleviate chronic sociated with substantial anxiety and frustration, and is char- testicular pain. C acterized by intermittent or constant unilateral or bilateral

Strength of recommendation (SOR) testicular pain, occurring for at least 3 months, that has a sig- nifi cant negative impact on activities of daily living and physi- A Good-quality patient-oriented evidence cal activity.1 B Inconsistent or limited-quality A variety of procedural and surgical options may help to patient-oriented evidence C Consensus, usual practice, minimize or alleviate chronic orchialgia. But which approach opinion, disease-oriented is best? Th ere are no evidence-based guidelines for the treat- evidence, case series ment of this condition, and no randomized controlled trials to

330 THE JOURNAL OF FAMILY PRACTICE | JUNE 2010 | VOL 59, NO 6 FIGURE 1 Chronic orchialgia: A diagnosis and treatment algorithm1,3,4,6,10

Conduct a thorough history and physical examination. Obtain midstream uirinalysis and testicular/ with color Doppler of spermatic cords.

Determine etiology if possible. Consider screening for STIs (eg, Chlamydia trachomatis, Neisseria gonorrhoeae) and treat if positive.

No defi nable etiology Treat underlying etiology: • Antibiotics – Empiric trials: – • Consider 1-month NSAID trial • Psychotherapy • Recommend scrotal elevation In about 25% –history of abuse • Consider antibiotic therapy for 4 weeks of cases –relationship stress (eg, quinolone) of chronic • Surgical intervention/urology consultation orchialgia, no –epididymal cyst cause is found. – If no satisfactory response: –nephrolithiasis Consider tricyclic antidepressant or gabapentin – nerve entrapment (eg, ilioinguinal, titrated to achieve maximal therapeutic benefi t genitofemoral) – –testicular or appendiceal torsion If no satisfactory response: –tumor • Consider psychiatry referral – • Consider urology referral for surgical or procedural therapy

NSAID, nonsteroidal anti-infl ammatory drug; STIs, sexually transmitted infections.

demonstrate the superiority of 1 modality over comes unbearable, he takes acetaminophen another. All diagnostic and treatment recom- or ibuprofen and takes a few days off from mendations are based on expert opinion de- exercising, which provides modest—but tem- rived from small cohort studies. porary—relief. With that in mind, we conducted a system- Vincent reports that he has had about a atic review of the literature evaluating medical dozen lifetime sexual partners and had chla- and surgical therapies for chronic testicular mydia over a decade ago as a college student. pain—and developed an algorithm (FIGURE 1), He is currently engaged and sexually monoga- along with the text and TABLE that follow, for mous, and tested negative for Chlamydia tra- family physicians (FPs) to use as a guide. chomatis, Neisseria gonorrhoeae, hepatitis, syphilis, and human immunodefi ciency virus CASE 1  Vincent B (HIV) at his annual health maintenance exam- Over the last few years, Vincent has had simi- ination last month. Shortly before that, Vin- lar episodes of bilateral testicular pain. He cent was treated empirically for epididymitis denies any history of direct trauma to the with a 4-week course of ciprofl oxacin, with , and he works out regularly by lift- no signifi cant improvement in symptoms. ing weights and running. When the pain be- He has no signifi cant past medical history,

JFPONLINE.COM VOL 59, NO 6 | JUNE 2010 | THE JOURNAL OF FAMILY PRACTICE 331 TABLE denies depression, and takes no prescription Causes of acute and chronic orchialgia1,3,4 medications. Physical examination reveals mild to mod- Acute erate diffuse tenderness to through- • Acute out the scrotum, including both testicles and • Epididymitis spermatic cords. There is no erythema of the scrotum. Nor are there any palpable scrotal • Inguinal hernia, strangulated masses, , or ; testicular, • Lumbosacral radiculopathy scrotal, or penile lesions; inguinal masses; or • (eg, mumps) lymph nodes. His urethral meatus is patent.

• The is smooth, nonnodular, and non- tender. The remainder of the physical exam is • /torsion of the appendix testis unremarkable. • Trauma

Chronic Determining a cause • Diabetic neuropathy can be a challenge Th ere are numerous possible causes of testicu- • Epididymal cyst/spermatocele lar pain (TABLE), including an inguinal hernia, • Epididymitis torsion of the , trauma, and a history of –Infectious (eg, Chlamydia trachomatis, Neisseria gonorrhoeae, chlamydia or gonorrhea, to name a few. Ureaplasma urealyticum, coliform bacteria) –Noninfectious (eg, refl ux of urine) Chronic testicular pain can also be psy- chogenic, often relating to a history of sexual • Fournier’s abuse or relationship stress. One study ex- • Gout amining comorbid psychological conditions • Henoch-Schönlein purpura in men with chronic orchialgia identifi ed a somatization disorder in 56% of the patients, • Herniated lumbar disc nongenital chronic pain syndromes in 50%, • and major depression or chemical dependen- 2 • Idiopathic swelling cy in 27%. Overall, however, estimates sug- gest that in about 25% of patients with chronic • Inguinal hernia orchialgia, no identifi able etiology is found. 1 • Interstitial cystitis

• Nephrolithiasis in the mid-ureter Establish a baseline with a physical exam Conduct a physical examination of the scro- • Orchitis (eg, mumps) tum, testes, spermatic cords, penis, inguinal • Polyarteritis nodosa region, and prostate as a baseline measure- • Previous surgical interventions ment in a patient who presents with chronic orchialgia.3,4 An initial urinalysis should be • Prostatitis performed to rule out infection or identify • Psychogenic (eg, history of sexual abuse, relationship stress) microscopic hematuria, which may prompt a • Referred pain from abdomen/ due to entrapment of genitofemoral more targeted work-up and therapeutic plan. or ilioinguinal nerve roots Take a thorough medical and psychosocial/ • Testicular cancer sexual history, as well. ❚ Order an ultrasound of the scrotum • Testicular vasocongestion from sexual arousal without ejaculation and testes, the accepted gold standard to • Torsion/torsion of the appendix testis highlight structural abnormalities of the tes- • Trauma ticles. Th e addition of color Doppler makes it possible to fi nd areas of hypervascularity, an • Varicocele indication of infl ammation in the testicle and • Vasectomy (postvasectomy pain syndrome) (FIGURES 2A AND B). Epididymal cysts are common fi ndings

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FIGURE 2 Well-circumscribed extratesticular mass A B IMAGES COURTESY OF: WILLIAM J. WEADOCK, MD

In the image at left, ultrasound reveals an anechoic mass (arrows), representing either an epididymal cyst or spermatocele, superior to the testicle (T). A color Doppler image (right) reveals increased vascularity to the epididymis (E), as compared with the testicle. Epididymal cysts are commonly on scrotal ultrasound; they are frequently in- ❚ Treat suspected STIs. Th e Centers for found on scrotal cidental, but may relate to the patient’s pain, Disease Control and Prevention report that in ultrasound; most depending on the size of the cyst. Smaller cysts men 14 to 35 years of age, epididymitis is most small cysts that that do not correlate with pain do not require commonly caused by chlamydia or gonorrhea.6 do not correlate treatment. Larger, painful cysts can be treated In males younger than 14 or older than 35, epi- with pain do with aspiration or injection with a sclerosing didymitis is most commonly caused by urinary not require agent—or with surgical excision, which off ers coliform pathogens, including Eschericia coli. treatment. the highest potential cure rate.3,4 A computed If epididymitis is suspected to be due to tomography (CT) scan without contrast is the chlamydia or gonorrhea, treatment should in- best way to fi nd genitourinary system calculi, clude either doxycycline 100 mg orally twice which could be the source of referred renal pain daily for 10 days or a single dose of azithromy- to the groin and scrotum. A contrast-enhanced cin 1 g orally (for chlamydia eradication) and a CT is best to evaluate for solid renal masses. single dose of ceftriaxone 125 mg intramuscu- larly (for gonorrhea eradication).6,7 If coliform bacteria is suspected, order a standard dose of Start with the most a quinolone (eg, ciprofl oxacin or levofl oxacin conservative treatment 500 mg/d) for 10 days.6 For refractory cases, In the absence of any fi ndings that require sur- treatment with a standard dose of a quinolone gical intervention, start conservatively. for 4 weeks is recommended.6 ❚ Initiate a trial of nonsteroidal anti- It is generally reasonable to treat most pa- infl ammatory drugs (NSAIDs) for at least tients empirically for suspected epididymitis 1 month. Although this is the standard fi rst-line with antibiotics if no other identifi able etiol- treatment, NSAIDs have been shown to help ogy can be determined. Multiple antibiotic only a small percentage of patients with chron- treatments should be avoided, however, in the ic orchialgia, and only on a short-term basis.1,3,4 absence of either an identifi able urogenital in- ❚ Recommend scrotal elevation with fection or ultrasound fi ndings consistent with supportive undergarments to decrease ve- epididymitis (eg, congestion and enlarge- nous congestion. Tell the patient, too, that ment). Antibiotics have not been shown to modifying his seated posture to avoid scrotal decrease the severity of chronic orchialgia and pressure may alleviate pain and poses no dis- their use, unless clearly indicated, may lead to cernible risk of worsening orchialgia.5 drug resistance.3 CONTINUED

JFPONLINE.COM VOL 59, NO 6 | JUNE 2010 | THE JOURNAL OF FAMILY PRACTICE 333 Consider a tricyclic antidepressant Postvasectomy pain is not unusual or gabapentin Several years after a vasectomy, the diameter Both tricyclic antidepressants (TCAs) and ga- of a man’s ejaculatory ducts often doubles in bapentin have demonstrated benefi t in the size to counteract the increase in fl uid pres- treatment of chronic pelvic and neuropathic sure.11 Th e specifi c cause of long-term post- pain.8,9 Doses should be titrated to achieve a vasectomy pain syndrome, or congestive maximal therapeutic benefi t while avoiding epididymitis, is unknown, but has been re- anticholinergic and neurologic side eff ects. ported in 5% to 43% of men who have under- A cohort study using a multidisci- gone this procedure.12-14 granulomas plinary team consisting of a psychologist, or spermatoceles represent the body’s eff ort an anesthetist, a physiotherapist, and an oc- to spare the testicle from damage second- cupational therapist found >50% symptom- ary to increasing fl uid pressure. While these atic improvement in 62% of men with chronic granulomas are benign lesions, their presence orchialgia treated with gabapentin up to may predispose a man to postvasectomy pain 1800 mg per day, and 67% of men treated syndrome.15-17 with nortriptyline up to 150 mg per day.10 However, a subgroup of patients who re- CASE 2  Jason H ported postvasectomy testicular pain did not Two months before Jason’s visit to the FP, his achieve a 50% symptomatic improvement testicular pain had become so excrutiating Up to 43% rate with either TCA or gabapentin therapy. that he went to the ED seeking treatment. of men who He was given an ultrasound with color Dop- undergo CASE 1  Vincent B pler and found to have postvasectomy surgical vasectomy The FP reassured Vincent that his physical changes consistent with bilateral spermato- develop examination was normal and recommended celes, but no evidence of epididymitis or a postvasectomy a 1-month trial of ibuprofen (600 mg every mass. Before leaving the ED, Jason received pain syndrome; 6 hours), and regular use of supportive briefs. ceftriaxone (125 mg IM) as gonorrhea pro- the specifi c Since the patient had been treated with an- phylaxis. He was discharged home with pro- reason is tibiotics in the past with no change in symp- phylactic antibiotics for chlamydia, as well as unknown. toms—and because he was thought to be at ibuprofen. He was advised to avoid strenuous low risk for an STI—the physician did not pre- physical activity and told to follow-up with his scribe another empiric trial of antibiotics. He FP if his symptoms did not improve. did send the patient for an ultrasound evalua- During several months of conservative tion of the scrotum and testes, which revealed medical therapy, including trials of NSAIDs, only a 0.5 x 0.4 x 0.6-cm right epididymal cyst quinolone antibiotics, TCAs, and gabapentin, that was not palpable on examination. Jason did not experience any signifi cant pain The patient returned after 1 month, not- relief. He was frustrated by the dull, aching ing that his symptoms had neither improved pain in his scrotum that continued to limit his nor worsened. The FP suggested that he stop physical and sexual activities. taking the ibuprofen and begin a trial of ga- Finally, the FP recommended a urologic bapentin 100 mg daily, titrating up to 3 times consultation. daily for the fi rst month, then to 300 mg 3 times daily in the second month. Consider these minimally When he returned 3 months later, Vincent invasive procedures reported that his symptoms had improved by When conservative medical management about 50%. He has since been able to increase fails, minimally invasive techniques are the both the intensity and frequency of physical next step. Th ere are 2 commonly used proce- activity. Vincent is not interested in further in- dures, both of which can be performed by a creasing the dose of gabapentin and declined urologist in an outpatient setting. a referral to a urologist for consideration of ❚ blocks with lidocaine procedural and surgical therapeutic options, and methylprednisolone have been shown to but agreed to follow up as needed if his tes- provide relief for weeks up to several months ticular pain worsened. in small case studies, and may be repeated

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at intervals of several months if modest relief algia related to postvasectomy pain syndrome is achieved.18,19 or chronic epididymitis. Reports highlighting ❚ Transrectal ultrasound-guided peri- symptomatic improvement based on small prostatic anesthetic injections, another case series range from 43% to 74%, with the microinvasive option, off ers minimal risk and highest success rate found during a 5½-year may provide some short-term relief. However, follow-up.23-25 In 1 study, 90% of patients re- data on long-term benefi t and resolution of ported that they were satisfi ed with their pain and disability are lacking.20 choice to undergo the procedure.25 ❚ Vasectomy reversal (vasovasostomy) and inguinal or scrotal should Consider surgery only after be considered only after all other treatment all else fails modalities have failed. Vasovasostomy has If all medical and conservative therapies have the potential to restore in up to 98% of been tried and the patient continues to have cases,26 which may or may not be desirable. debilitating pain, surgical options should be One study of men who experienced post- considered. Because current surgical thera- vasectomy pain syndrome and underwent pies are not always eff ective and are not re- microsurgical vasovasostomy found that after versible (and research on the various options nearly 2½ years, 84% experienced complete is limited), it is important to initiate a detailed pain resolution.27 discussion with the patient. Such conversa- Th e goal of orchiectomy is to relieve or- Denervation of tions should be held in consultation with chialgia by releasing the entrapped ipsilat- the spermatic a urologist. eral genitofemoral and/or ilioinguinal nerves. cord should Highlight risks and benefi ts and provide One study determined that 90% of men who be considered realistic expectations of short- and long-term underwent unilateral epididymectomy for only for patients postsurgical outcomes. It is also important chronic orchialgia required an orchiectomy who have to address psychological factors and social to resolve pain.1 Another study found that experienced stressors that often contribute to chronic pel- 80% of patients continued to suff er both temporary relief vic pain syndromes, which can improve long- short- and long-term debilitating orchialgia from spermatic term outcomes regardless of the chosen postorchiectomy.28 cord injection treatment. For this reason, a referral to a psy- and have tried chiatrist may be indicated. CASE 2  Jason H all conservative ❚ Microsurgical denervation of the Jason saw a urologist, who initially offered measures. spermatic cord. Removal of the aff erent nerve him bilateral spermatic cord blocks. They pro- stimulus to the testicle is believed to result in vided Jason with moderate symptom relief on the downregulation of the peripheral and cen- most days of the week and allowed him to in- tral nervous systems, so the patient no longer crease his physical and sexual activities. Three has the perception of testicular pain. Several months later, Jason went back to the urologist small trials have yielded favorable symptom- for evaluation because he felt that the effects atic pain relief scores in up to 71% of patients, of the spermatic cord blocks had worn off. In with reported adverse outcomes including the next 6 months, he had 2 additional bilat- rare testicular atrophy—but no complaints of eral blocks. hypoesthesia or hyperesthesia of the scrotum, Nearly a year after a series of spermatic penile shaft, inguinal, or medial thigh skin.21,22 cord blocks, most of it spent in persistent dis- Th is treatment should be considered only in comfort, Jason returned to his FP with a re- patients who have experienced a signifi cant quest for narcotic pain medication. The FP degree of temporary relief from spermatic tried to be supportive, but told Jason that cord injection. chronic narcotic therapy was not an ideal ❚ Epididymectomy is recommended choice—and referred him back to the urolo- only when pain is localized to the epididy- gist to discuss surgical options. mis, as this is a testicle-sparing procedure. The urologist recommended a bilateral Unilateral or bilateral epididymectomy is a vi- epididymectomy and the patient, who was able option for the treatment of chronic orchi- desperate to obtain some pain relief and now

JFPONLINE.COM VOL 59, NO 6 | JUNE 2010 | THE JOURNAL OF FAMILY PRACTICE 335 regretted undergoing a vasectomy, agreed. ual activities—and he continues to be pleased Within the fi rst few weeks after his surgery, he with the outcome of his treatment. JFP noticed a reduction in pain, and he slowly in-

creased his physical activity. A year later, Jason CORRESPONDENCE reported only minimal testicular and scrotal Joel J. Heidelbaugh, MD, FAAFP, Ypsilanti Health Center, 200 Arnet, Suite 200, Ypsilanti, MI 48198; jheidel@ discomfort that did not limit his physical or sex- umich.edu

References 1. Davis B, Noble MJ, Weigel JD, et al. Analysis and management 15. Christiansen CG, Sandlow JI. Testicular pain following vasec- of chronic testicular pain. J Urol. 1990;143:936-939. tomy: a review of postvasectomy pain syndrome. J Androl. 2. Schover LR. Psychological factors in men with genital pain. 2003;24:293-298. Cleve Clin J Med. 1990;57:697-700. 16. Shapiro EI, Silber SJ. Open-ended vasectomy, sperm granuloma, 3. Masarani M, Cox R. Th e aetiology, pathophysiology and man- and postvasectomy orchialgia. Fertil Steril. 1979;32:546-550. agement of chronic orchialgia. Br J Urol Int. 2003;91:435-437. 17. Taxy JB, Marshall FF, Erlickman RJ. Vasectomy: subclinical 4. Granitsiotis P, Kirk D. Chronic testicular pain: an overview. Eur pathologic changes. Am J Surg Pathol. 1981;5:767-772. Urol. 2004;45:430-436. 18. Fuchs E. Cord block anesthesia for scrotal surgery. J Urol. 5. Coogan CL. Painful scrotum. In: Myers JA, Millikan KW, Sacla- 1982;128:718-719. rides TJ, eds. Common Surgical Diseases. New York: Springer; 19. Issa M, Hsiao K, Bassel Y, et al. Spermatic cord anesthesia block 2008:293-295. for scrotal procedures in the outpatient clinic setting. J Urol. 6. Centers for Disease Control and Prevention. Sexually transmit- 2004;172:2358-2361. ted diseases treatment guidelines, 2006. MMWR Morb Mortal 20. Zorn B, Rauchenwald M, Steers WD. Periprostatic injec- Wkly Rep. 2006;55(RR-11):1-94. tion of local anesthesia for relief of chronic orchialgia. J Urol. 7. Newman LM, Moran JS, Workowski KA. Update on the man- 1994;151:411,A735. Addressing agement of gonorrhea in adults in the United States. Clin 21. Levine LA, Matkov TG, Lubenow TR. Microsurgical denerva- Infect Dis. 2007;44(suppl 3):S84-S101. tion of the spermatic cord: a surgical alternative in the treat- psychological 8. Wiff en PJ, McQuay HJ, Rees J, et al. Gabapentin for acute and ment of chronic orchialgia. J Urol. 1996;155:1005-1007. factors and chronic pain. Cochrane Database Syst Rev. 2005;(3):CD005452. 22. Strom KH, Levine LA. Microsurgical denervation of the sper- 9. American College of Obstetricians and Gynecologists. Chronic matic cord for chronic orchialgia: long-term results from a social stressors pelvic pain. ACOG Practice Bulletin No. 51. Obstet Gynecol. single center. J Urol. 2008;180:949-953. that often 2004;103:589-605. 23. Padmore DE, Norman RW, Millard OH. Analyses of indications 10. Sinclair AM, Miller B, Lee LK. Chronic orchialgia: consider ga- for and outcomes of epdidymectomy. J Urol. 1996;156:95-96. contribute to bapentin or nortriptyline before considering surgery. Int J Urol. 24. West AF, Leung HY, Powell PH. Epididymectomy is an eff ec- chronic pelvic 2007;14:622-625. tive treatment for scrotal pain after vasectomy. Br J Urol Int. 11. Jarow JP, Budin RE, Dym M, et al. Quantitative pathologic 2000;85:1097-1099. pain syndromes changes in the human testis after vasectomy. N Engl J Med. 25. Siu W, Ohl DA, Schuster TG. Long-term follow-up after epididy- can improve 1985;313:1252-1256. mectomy for chronic epidiymal pain. Urology. 2007;70:333-336. 12. Choe J, Kirkemo A. Questionnaire-based outcomes 26. Patel SR, Sigman M. Comparison of outcomes of vasovasos- long-term study of nononcological post-vasectomy complications. tomy performed in the convoluted and straight . J outcomes. J Urol. 1996;155:1284-1286. Urol. 2008;179:256-259. 13. McMahon A, Buckley J, Taylor A, et al. Chronic testicular pain 27. Myers SA, Mershon CE, Fuchs EF. Vasectomy reversal for following vasectomy. Br J Urol. 1992;69:188-191. treatment of the post-vasectomy pain syndrome. J Urol. 14. Ahmed I, Rasheed S, White C, et al. Th e incidence of post-va- 1997;157:518-520. sectomy chronic testicular pain and the role of nerve stripping 28. Costabile RA, Hahn M, McLeod DG. Chronic orchialgia (denervation) of the spermatic cord in its management. Br J in the pain prone patient: the clinical perspective. J Urol. Urol. 1997;79:269-270. 1991;146:1571-1574.

Issues in postmenopausal hormone therapy FREE 0.5 CME DEPRESSION, ENDOMETRIAL HEALTH, CREDIT AND DISCONTINUATION

CASE 1 HT and new-onset depression Nanette F. Santoro, MD

CASE 2 Estrogen and endometrial health Veronica A. Ravnikar, MD, FACOG

CASE 3 Discontinuing HT James H. Liu, MD

Both physicians and patients report being confused by confl icting reports of the safety and effi cacy of hormone therapy (HT). In this supplement to Sexuality, Reproduction and Menopause, 3 experts use case-based evidence to off er suggestions for prescribing HT to postmenopausal women who experience depression or vasomotor symptoms, or who want to discontinue HT. Available online at http://www.srm-ejournal.com/srm.asp?id=8035

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