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Practical Surgical Management of Chronic Testicular Pain

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Practical Surgical Management of Chronic Testicular Pain FEATURE Practical surgical management of chronic testicular pain BY MOHAMMAD HASSAN KHAN AND NAEEMUDDIN AHMED SHAIKH hronic testicular pain (CTP) treatments recommended in the published examination may pinpoint the painful area, is defined as constant or literature for CTP. In our unit a senior and digital rectal examination is undertaken intermittent, unilateral or bilateral consultant urologist with a special interest to evaluate pelvic floor and prostate. We Ctesticular pain of more than in the management of CTP looks after all recommend scrotal examination both in three months’ duration, which significantly referrals with this condition, including laying and standing position, in particular interferes with the daily activities of the regional referrals. At least 20% of referrals to elicit signs suggestive of varicocele, or patient prompting medical advice [1-4]. are from regional centres. We believe retraction of testis in the standing position This condition is commonly seen by that every patient with CTP should be indicating hyperactive cremaster muscle. urologists and is difficult to treat. It is often thoroughly assessed, investigated and Urine examination and an ultrasound frustrating, both for urologists and patients, offered treatment depending on the clinical examination of testes are first-line because of multiple aetiological factors findings and aetiological factors. investigations. CT scan of abdomen and MRI which contribute to it, and the absence of In this feature article, we discuss the of spine are also considered, depending on a standardised, widely accepted treatment surgical management of CTP and report the the clinical suspicion of the source of pain. algorithm and care [5]. In almost every outcome data for procedures performed by Increased intravesical pressure may be case there is a need for bespoke treatment. a single urologist over a five-year period. associated with testicular pain as well [10]. There are 100,000 cases of chronic testicular pain every year in the USA and Patient evaluation Differential diagnosis the incidence is increasing because of rising A thorough history is crucial in the These include chronic epididymitis, post- health awareness [6]. Chronic testicular assessment of the patient, including the vasectomy pain syndrome, intermittent pain is one of the commonest reasons for relevant medical, sexual and surgical torsion, hyperactive cremaster muscle, medical discharge from the US army [7]. In history. It’s important at this stage to rule varicocele, and referred pain secondary the majority of cases pain is idiopathic (up out non-scrotal aetiological factors causing to interstitial cystitis, chronic prostatitis, to 50%), while in the rest pain is related distal ureteric stone, and intervertebral disc to previous infection or trauma [1,5]. Post referred pain from musculoskeletal or intra- prolapse. vasectomy pain syndrome is documented abdominal pathology (e.g. distal ureteric in up to 19% of men undergoing vasectomy stone). It is important to ask for duration, [8]. The BAUS vasectomy information leaflet nature and any trigger factors for the pain. Surgical management quotes a 5-30% risk of chronic testicular Physical examination of the groin Failed medical management with analgesia pain [9]. and genitals is undertaken, as well as and a surgically motivated patient prompts There are several medical and surgical examination of the abdomen. Scrotal surgical intervention. Almost all patients “This condition is often frustrating, both for urologists and patients, because of multiple aetiological factors which contribute to it, and the absence of a standardised, widely accepted treatment algorithm and care.” Figure 1 urology news | JANUARY/FEBRUARY 2019 | VOL 23 NO 2 | www.urologynews.uk.com FEATURE Figure 2 Figure 3 have been on fairly strong analgesics prior ascending to the groin with physical activity in two layers. This procedure is not very to referral to us, including co-codamol, and causing pain. Pain settles down once popular with patients because of reversal pregablin, gabapentin and amitriptyline. testis is manually brought down to the of fertility. This procedure can also be We have used cord block (local anaesthetic scrotum. This procedure is performed offered after failure of spermatic cord nerve + steroids) in a number of patients prior to through inguinal incision and complete stripping. The published evidence suggest a advising for stripping of the cord with varied division and ligation of cremaster is done. 75-90% success rate [13]. results. It does not always predict if the This procedure is very safe with minimal risk surgery will be successful. of infection and haematoma. Orchidectomy Extirpative surgery is recommended as a Microsurgical spermatic cord nerve Bilateral testicular fixation last resort in the published literature. In stripping Intermittent testicular torsion typically unilateral conditions it may be considered This procedure is advised in patients with presents as testicular pain, which is self- after failed medical and surgical treatments. post vasectomy and idiopathic chronic limiting and lasts for few minutes to few In the case of bilateral pain, before testicular pain. It involves inguinal incision hours, in a younger population. Completely offering orchiectomy it is advised to take and microsurgical dissection of the normal physical examination and normal a multidisciplinary approach. A thorough psychosomatic assessment and chronic spermatic cord with preservation of only ultrasound scan would help to exclude any pain team input is sought. We advise to the testicular artery, vas deferens and vein other pathology. Procedure is performed avoid orchidectomy whenever possible. [Figure 1]. Use of an operating microscope through a midline scrotal incision, and Documented improvement in pain varies is usually recommended. However, we use bilateral three-point fixation is done with surgical magnifying loops with equally 2/0 Vicryl or PDS. good results. Risks associated with this procedure, which patients are counselled Vasectomy reversal for, include testicular atrophy, hydrocele, Vasectomy reversal is an option for post infection and haematoma. This procedure “A thorough history is vasectomy chronic pain syndrome when is believed to work through destruction of all other options fail. This procedure is degenerated cord nerves that are found crucial in the assessment of recommended for patients with epididymal in the cremaster muscle fibres, spermatic congestion type dull pain and pain after the patient, including the fascia, and in relation to the vas deferense ejaculation. On examination the epididymis and the internal spermatic arteries [11]. relevant medical, sexual may be tender and feels bulky. We perform It is successful in 60-90% of cases [12]. end-to-end vaso-vasostomy with 7/0 PDS and surgical history.” Infrequently a large lipoma is encountered during exploration of the spermatic cord [Figure 2 and 3]. We have observed it in 20% Table 1. of cases. This is excised. We are uncertain Procedure Number of patients % response about the significance of the presence of lipoma of the cord and effects of its removal Spermatic cord nerve stripping 35 91% on final outcome. Cremaster muscle division 21 100% Bilateral testicular fixation 9 100% Division of cremaster muscle Vasectomy reversal 3 100% Cremaster muscle division is recommended Epidydimo-vasostomy 1 100% in patients with hyperactive cremaster Total 69 99% muscle. They have very mobile testicles, urology news | JANUARY/FEBRUARY 2019 | VOL 23 NO 2 | www.urologynews.uk.com FEATURE between 20% and 70% [14]. There is patients who have had no response to a also a 25% association with ‘phantom conservative approach. The management testicular pains’ [15]. We have not done any of CTP is challenging and decisions on “Provided care is taken to orchidectomy in our unit for CTP. the appropriate operative procedure is largely based upon a thorough history and make a correct diagnosis Our data over last five years. examination. Provided care is taken to make and an appropriate surgical We have prospectively collected our a correct diagnosis and an appropriate outcomes data from January 2013 in a surgical procedure is carried out then the procedure is carried out handwritten diary maintained by the team. outcome can be excellent. The surgical Preoperative findings and differential options should be offered to patients if a then the outcome can be diagnosis are recorded. The operative correct diagnosis is made at the outset as excellent.” procedure and operative surgeon data the outcomes may be rewarding. are also recorded, as are the outcomes from patient review in the follow-up clinic References (Table 1). 1. Davis BE, Noble MJ, Weigel JW, et al. Analysis and A total of 69 patients were operated management of chronic testicular pain. J Urol 1990;143:936-9. on for chronic testicular pain in our unit. 2. Tan WP, Levine LA. What can we do for chronic scrotal All operations were either performed or content pain? World J Men Health 2017;35(3):146-55. AUTHORS supervised by a single consultant urological 3. Tan WP, Levine LA. An overview of the management surgeon (Mr Naeemuddin Shaikh). The of post-vasectomy pain syndrome. Asian Journal of Andrology 2016;18:332-7. surgical procedures performed on these 4. Tan WP, Tsambarlis PN, Levine LA. Microdenervation of 69 patients were: spermatic cord nerve the spermatic cord for post‐vasectomy pain syndrome. stripping – 35 (50.72%), cremaster muscle BJUI 2018;121(4):667-73.
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