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What Can We Do for Chronic Scrotal Content Pain?

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What Can We Do for Chronic Scrotal Content Pain? pISSN: 2287-4208 / eISSN: 2287-4690 World J Mens Health 2017 December 35(3): 146-155 https://doi.org/10.5534/wjmh.17047 Review Article What Can We Do for Chronic Scrotal Content Pain? Wei Phin Tan, Laurence A Levine Department of Urology, Rush University Medical Center, Chicago, IL, USA 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. Key Words: Chronic pain; Epididymis; Epididymitis; Pelvic pain; Vasovasostomy INTRODUCTION mately 2.5% of all urology visits are associated with scro- tal content pain, resulting in a significant healthcare finan- Chronic scrotal content pain (CSCP) is defined by at cial burden [1,5]. Many patients with this condition end up least 3 months of chronic or intermittent scrotal content seeing physicians across many disciplines, further frustrat- pain with severity that interferes with daily activities, ing them [6,7]. prompting the patient to seek medical treatment [1]. CSCP In recent years, physicians are seeing more patients may originate from the testicle, epididymis, paratesticular with CSCP due to the increased awareness of men’s health structures, and/or the spermatic cord. The etiology of the [8]. It is estimated that around 100,000 men suffer from pain is idiopathic in up to 50% of patients [2]. Easily recog- this problem, and the number will continue to increase nizable and reversible causes include varicocele, epi- [9]. It is estimated that chronic pain affects around 116 mil- didymitis, spermatocele, tumor, infection, and torsion. lion Americans, leading to $635 billion being spent on This syndrome has been referred to by many names, in- medical expenses and lost productivity per year due to this cluding chronic orchialgia, testicular pain syndrome, tes- problem [10]. tialgia, CSCP, post-vasectomy orchialgia, post-vasectomy Multiple algorithms have been proposed, but none pain syndrome (PVPS), congestive epididymitis, and have been validated [2,4]. It is recommended that pharma- chronic testicular pain. Presently, this problem is referred cotherapy options should be exhausted before consider- to as CSCP, as this term appears to best encompass the va- ing surgical treatments, which include epididymectomy, riety of structures that may be involved [3,4]. Approxi- microdenervation of the spermatic cord (MDSC), vasec- Received: Oct 12, 2017; Revised: Oct 22, 2017; Accepted: Nov 12, 2017 Correspondence to: Laurence A Levine Department of Urology, Rush University Medical Center, 1725 W Harrison Street, Suite 352, Chicago 60612, IL, USA. Tel: +1-312-563-5000, E-mail: [email protected] Copyright © 2017 Korean Society for Sexual Medicine and Andrology This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons. org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Wei Phin Tan and Laurence A Levine: Chronic Scrotal Content Pain 147 tomy reversal, and finally orchiectomy. In this article, we further mediators of WD, such as interleukin 1α [14]. aim to review the workup and treatment options available Any organ that shares the same nerve pathways with the for CSCP. scrotal content (L1∼L2 and S2∼S4) may refer pain to this area. Lower back pain due to irritation of the nerve root of METHODOLOGY T10∼L1 may radiate to the testicle, as they share the same innervation. Pain arising in the ureter due to obstruction, We conducted a computerized bibliographic search of hip pain and intervertebral disc prolapse, or pudendal the PubMed, Medline, Embase, and Cochrane databases neuropathies can all result in CSCP [15]. The pain could al- for all reports pertaining to CSCP using the Medical so be part of chronic prostatitis/chronic pelvic pain syn- Subject Headings keywords “Chronic scrotal content drome, for which up to 50% of men have reported to also pain”, “Testicular pain”, “Orchialgia”, “Testicular Pain have pain in the testes [2]. Ultimately, CSCP can arise from Syndrome”, “microdenervation of the spermatic cord”, any traumatic, infectious, or irritative stimulus to the “Post-vasectomy Pain Syndrome”, and “testialgia” through nerves in the scrotum [16]. 15th September 2017. All studies pertaining to CSCP were included in the review. Studies were excluded if they were CLINICAL PRESENTATION AND published in languages other than English. EVALUATION ETIOLOGY/PATHOPHYSIOLOGY The signs and symptoms of CSCP include orchialgia, tender epididymis, tender vas, dyspareunia, pain with The iliohypogastric, ilioinguinal, genitofemoral, and ejaculation, premature ejaculation, pain with straining, pudendal nerves originate from the L1∼L2 and S2∼S4 and pain after prolonged sitting. The key to a successful nerve roots and are responsible for innervation of the evaluation is to establish a good rapport with the patient. testes, epididymis, and scrotum [1,11]. These nerves in- The evaluation of a patient presenting with scrotal content nervate the scrotal content and travel through the sper- pain should include a thorough history and physical ex- matic cord. At least 50% of the nerves innervating those amination with a focused examination of the scrotal structures were identified near the vas deferens and 20% content. The history portion of the clinical visit should in- were identified in the cremasteric fascia [12]. The patho- clude the duration and nature of the pain (sharp, aching, physiology of CSPS is multifactorial and poorly under- burning, pressure, etc.), consistency (intermittent or con- stood. An injury to the testes or other scrotal content struc- stant), severity (on a 0∼10 visual analogue scale), varia- tures is typically the precursor of CSPS. This acute pain tion in intensity, location, radiation, aggravating factors, leads to nerve sensitization, resulting in modulation of the associated symptoms, and previous therapeutic maneu- nerve pathways, causing hypersensitivity around the sper- vers. The patient should be asked whether the pain is asso- matic cord. This hypersensitivity has been proposed to fol- ciated with voiding, bowel movements, sexual or physical low neural injury, with resulting Wallerian degeneration activities, or prolonged sitting. A surgical history pertain- (WD) in these peripheral nerves. WD is characterized as ing to the spine, inguinal, scrotal, pelvic, and retro- an auto-destructive change in both the proximal and distal peritoneal space should also be documented. A thorough nerve axons, which leads to an environment clear of in- psychosocial exam to rule out depression, a history of sex- hibitory debris and supportive of axon regrowth and func- ual abuse, Munchausen syndrome, or other somatoform tional recovery [13]. Following nerve injury, calcium en- disorders should also be included in the evaluation ters the cell, triggering the sealing of the proximal and dis- [17,18]. tal axonal stump by the fusion of axolemmal vesicles A thorough physical examination focusing on the geni- around the injured axon endings. This also activates cal- talia is essential for a patient presenting with scrotal con- cium-dependent protease pathways, such as phospholi- tent pain. The patient should be examined while standing pases and M-calpain. M-calpain triggers the expression of and supine, beginning on the normal/less painful side. A www.wjmh.org 148 World J Mens Health Vol. 35, No. 3, December 2017 focused examination of the testicles, epididymides, and cele, or infection [19,20]. A magnetic resonance imaging vas deferens is recommended, as well as a 360° digital scan of the spine and/or hips is also recommended when rectal exam to evaluate abnormalities of the prostate and there is a history of back or hip pain to rule out nerve hypertonicity or tenderness of the pelvic floor structures. impingement. A spermatic cord block (SCB) should also A neurological examination of the lower limbs should also be performed to determine if the pain is being generated be performed to rule out radicular pain syndromes and from within the scrotum. We recommend that this block neurosensory deficits. Laboratory investigation studies be performed by injecting 20 mL of 0.25% bupiva- should include a urinalysis and urine and semen culture to caine/ropivacaine without epinephrine into the spermatic rule out infection when indicated. Should microscopic cord at the level of the pubic tubercle [17]. If the pain sig- hematuria be identified on the urinalysis, a computed to- nal is conducted via the spermatic cord nerves, the pain mography scan of the abdomen and pelvis is indicated, as should be temporarily relived after performing the cord obstructing stones in the ureter (particularly the intramural block. The differential diagnoses for CSPS include con- portion of the ureter) can result in scrotal content pain. stipation; hydrocele; varicocele; epididymitis; tumor; in- The use of scrotal ultrasound in men with chronic orchi- termittent testicular torsion; inguinal hernia; aortic
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