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I.7.5 Testicular Pain and Related Pain Syndromes T.B

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I.7.5 Testicular Pain and Related Pain Syndromes T.B 170 I.7 Problem: Emergencies in Andrology I.7.5 Testicular Pain and Related Pain Syndromes T.B. Hargreave, L. Turner-Stokes Key Messages I.7.5.1.3 ■ In acute pain, it is important to diagnose Chronic Testicular Pain and Chronic Testicular Pain testicular torsion quickly, and if torsion is Syndromes suspectedthenanexploratoryoperationdoes no significant harm, even if the diagnosis Chronic testicular pain (orchalgia or orchiodynia) is subsequently proves to be epididymo-orchitis, defined as pain in the testicle and surrounding areas whereas a missed torsion results in loss of the that has been present for more than 6 months. There is testicle. a spectrum of conditions ranging from chronic recur- ■ It is good practice to use local anaesthetic as a ring epididymal pain such as may occur following supplement to general anaesthesia for all vasectomy to a complete disabling chronic pain syn- andrological surgery to ensure a pain-free drome. These conditions pose a considerable manage- postoperative recovery, as there is evidence ment problem for both the patient and his doctor. that poor pain control may trigger chronic pain. ■ The first step in the management of chronic I.7.5.2 testicular pain is to take a detailed history and Aetiology and Pathogenesis complete a careful clinical examination. I.7.5.2.1 ■ If the diagnosis is chronic testicular pain and Acute Testicular Pain – Pathogenesis provided ilio-inguinal pain and other pathology has been excluded, a spermatic cord Acute testicular pain can be caused by a variety of con- denervation operation may help in up to 75% ditions affecting the testicle. Perhaps the commonest of men, but there is a risk that further surgery cause of pain is epididymo-orchitis. Other causes are can make chronic pain worse. torsion,bleedingintoatesticulartumourorbleeding I.7 ■ Long-term management of chronic neuro- into hydroceles, epididymal cysts, and spermatoceles. pathic testicular pain is best undertaken by Classically, testicular tumours are described as pain- chronic pain specialists and rehabilitation less, but up to 40% of patients report dull aching or medicine experts and centres on encouraging heaviness. the man to lead as normal a life as possible despite the pain. I.7.5.2.2 Neuropathic Testicular Pain – Pathogenesis Less commonly, testicular pain may arise from neuro- I.7.5.1 logical injury (neuropathic pain). The nervous supply Definition of the Disease to the testicle and scrotum is complex, and in order to understand the basis for neuropathic syndromes pre- I.7.5.1.1 senting with testicular pain, it is necessary to have Acute Testicular Pain some understanding of the relevant neuroanatomy Acute pain in the testicle area can occur secondary to a (Fig. I.7.16; Wesselmann et al. 1997). variety of conditions affecting the testicle and epididy- ■ Pain sensation to the testis is supplied mainly mis. Thus acute testicular pain is defined as the noci- through sympathetic fibres from T10–L1. These ceptive response to local testicular or epididymal pa- travel via the superior hypogastric plexus (SHP) thology. and are then carried in the spermatic plexus along spermatic cord structures to terminate in the testis, I.7.5.1.2 epididymis and vas deferens. Testicular Pain of Neuropathic Origin ■ Asecondsensorysupplyisderivedfromthe genito-femoral nerve (L1–L2), which takes a retro- This is defined as testicular pain caused by lesion in- peritoneal route. The genital branch of this nerve volving the testicular nerve supply. travels down the inguinal canal to supply the cremaster, cord and tunica vaginalis. ■ The posterior sacral nerves (S2–S3) provide a subsidiary supply via the sacral plexus and the I.7.5 Testicular Pain and Related Pain Syndromes 171 I.7 Fig. I.7.16. Innervation of the testicle. From Wesselmann et al. (1997) pudendal nerve, to innervate a portion of the scrotum. – Laparoscopic donor nephrectomy – Kim et al. Compression of the pudendal nerve is reported to be a (2003) noted ipsilateral orchalgia occurred in 14 cause of scrotal pain (Kim et al. 2003), which may re- of 145 patients (9.6%) spondonoccasiontodecompression. ■ Generalized neuropathic conditions such as diabetes, alcoholic neuropathy or polyarteritis Testicular pain of neuropathic origin may be the result nodosa of (Wesselmann et al. 1997): ■ Referred pain – occasionally testicular pain may be ■ Entrapment neuropathies due to: referred from the hip or ureter – Inguinal hernias – (ilio-inguinal or genito- femoral nerve) I.7.5.2.3 – Aneurysmal dilatation of the common iliac Testicular Chronic Pain Syndrome – Pathogenesis artery (genito-femoral nerve) – Retroperitoneal fibrosis – testicular pain in this Whilst more acute forms of pain are driven by nocicep- situation usually associated with abdominal or tive responses to local pathology, once pain has low back pain persisted for more than a few months, other factors – Spinal or sacral pathology – e.g. due to a come into play, such as psychological, emotional or prolapsed intervertebral disc behavioural responses, and this combination of factors ■ Local nerve damage may follow local surgical may lead to a chronic pain syndrome. In this situation, procedures, including: the pain may no longer be relieved by simple medical or – Vasectomy surgical interventions and a more holistic approach is – Hernia repair required. 172 I.7 Problem: Emergencies in Andrology Chronic pain syndromes involving the limbs with identifiable triggering episode. This may be an episode somatic and autonomic nerve involvement have been of very severe pain (e.g. torsion or undertaking a vasec- recognized for many years. Alternative names to de- tomy without ensuring adequate local anaesthesia) or scribe the various manifestations of chronic pain syn- prolonged pain, for example, from a varicocele. Alter- dromes include causalgia, reflex sympathetic dystro- natively there might be ischaemic damage following or- phy, algodystrophy, and chronic neuropathic pain and chitis or orchiopexy. Not infrequently, there is an am- haveoftenbeenusedinterchangeably.Thecurrent plifying event such as a second operation, for example, term “complex regional pain syndrome” has been epididymectomy undertaken to try to relieve minor coined to emphasize the complex interaction of somat- chronic epididymal discomfort. In a typical scenario, ic, psychological and behavioural factors and the non- further surgery is recommended to try to cure the localized distribution of symptoms (Harden et al. source of pain and with each episode of surgery there 1999). Pain rarely follows a recognized anatomical or may be a period of temporary relief but ultimately the neuro-anatomical distribution. pain recurs and is often worse. To this extent, there is In more recent years, there has been a realization always a risk that surgical procedures may amplify pain that there are a number of these syndromes involving and this risk, which is unquantifiable, has to be ex- the internal organs and predominantly the autonomic plained to men when recommending surgical opera- nerve pathways. Examples include chronic heart pain, tions to try to cure testicular pain. loin pain syndromes (Sockeel et al. 2004; Chapuis et al. There is no test that defines chronic testicular pain 2004; Greenwell et al. 2004), chronic pelvic pain (Jani- and the assessment is based on clinical criteria. In the cki et al. 2003), including some manifestations of transition, the pain may become less well localized and chronic prostatitis. A common feature of all of these there may be paraesthesia. Unlike other neuropathic syndromes is chronic pain which is disproportionate in pain conditions, scrotal skin oedema and skin colour intensity, distribution and duration to the underlying changesareuncommon,probablybecausetheinnerva- pathology (Dunn 2000). The pain syndrome may or tion of the testis is entirely separate from the scrotal may not follow a triggering event such as an episode of wall. Autonomic nerves and autonomic pain fibres very severe pain or an injury, which is often trivial. In travel to the testicle in close proximity to the testicular addition, there may be manifestations of sympathetic artery, vas deferens and blood vessels in the cord, I.7 overactivity, such as skin oedema, excess sweating, skin whereas scrotal skin innervation is from terminal colour and temperature changes, and this has led to the branches of the ilio-inguinal nerve. If scrotal skin oede- term “sympathetically maintained pain”, although the ma and colour changes are part of the clinical picture, physiological role of the sympathetic nervous system then it is more likely that the chronic pain syndrome re- remains unclear. lates to a problem with the ilio-inguinal nerve than The pathology of chronic pain syndromes is not fully from a trigger in the testis. understood, but it is thought that there is a facilitation of pain nerve pathways at several different levels in the Postvasectomy Pain brain (Janig and Baron 2003), spinal cord and peripher- al nerves. The process has the unfortunate result that Postvasectomy pain is typically a localized tenderness pain signals are felt at thresholds that would not nor- or pain or extreme pain on palpation over the epididy- mally reach consciousness. The appreciation of pain is mis, and except in the most severe cases, this can often more extreme (hyperalgesia) and even mild stimulation be distinguished by careful clinical examination from is felt as pain (allodynia). In the case of chronic testicu- pain in the testicle. In approximately 25% of cases, no lar pain, stimuli that would normally pass unnoticed cause for orchalgia can be found. It has been reported such as pressure from tight underwear or sitting with to occur in up to one-third of patients, but long-lasting legs crossed can cause noticeable discomfort or pain. pain sufficient to cause the man to regret vasectomy Any subsequent inflammation or injury, including sur- was reported in 3 men of 172 (1.7%) who responded to gical operations, may have the effect of further facilitat- the survey (McMahon et al. 1992) and in another sur- ing pain nerve pathways and amplifying the pain.
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