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 peripheral 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. Thus vey in 3 out of 188 (1.6%) men who responded 10 years any further surgery such as epididymectomy for post- later [3/460 (0.7%) who were sent the questionnaire; vasectomy epididymal pain, or even denervation opera- Manikandan et al. (2004)]. These two surveys indicate tions, can make the problem very much worse. that bothersome scrotal pain is more frequent than the 1 in 1,000 figure that is quoted in the literature; however, in a survey of recent prospective randomized trials The Relationship Between Acute and Chronic of different vasectomy techniques, chronic pain was Testicular Pain not identified as a problem (Aradhya et al. 2005), indi- The relationship between acute and chronic testicular cating that this complication may be technique-depen- pain is by no means clear. In some cases, there in an dent. There is a need for better information about the I.7.5 Testicular Pain and Related Pain Syndromes 173 incidence of postvasectomy bothersome chronic pain tercourse. Testicular pain associated with infection is and also exploration of ways to prevent it. Some au- usually associated with urinary symptoms such as thors have suggested that pain may be prevented by frequencyorurgencyorthoseofsexuallytransmitted leaving the testicular end of the vas unligated – the so- diseases such as urethral discharge. called open-ended vasectomy (Shapiro and Silber Assessment should routinely include a careful his- 1979) tory, examination and urinalysis. Ultrasound of the testis is essential in acute presentations and usually I.7.5.3 worthwhile also in the chronic situation. Many men with chronic pain are worried about malignancy and Clinical Findings: History, Physical Examination, a negative ultrasound scan enables the clinician to Technical Investigations, Laboratory Findings give reassurance with authority. The scan may also The diagnosis of testicular pain is usually made on the give diagnostic information such as the presence of a basis of careful history and examination, together with thickened epididymis with a sperm granuloma. Tes- basic urological investigation to reveal the causes. A ticular microcalcification is a relatively frequent find- practical guide to assessment is given in Box 1. ing on ultrasound but although there have been some Testicular pain may be: reports of an association with testicular pain (Mac- Kinnon et al. 1990), it is a frequent finding in men who ■ Unilateral or bilateral have no pain. More detailed imaging (e.g. MRI) is ■ Intermittent or constant rarely necessary, but occasionally may serve a thera- ■ Focal or radiating – for example to the groin, peutic purpose in providing reassurance to patient abdomen, pelvis, perineum, legs, or back and doctor alike. Usuallythereisnointerferencewithsexualfunction, but pain postvasectomy is often more marked after in-

Box 1: Assessment of the patient with testicular pain – a practical guide History: ■ Vascular system – to exclude arteriopathy or I.7 Pain history aneurysmal dilatation ■ Duration, character, radiation, exacerbating and 1. Record presence of peripheral pulses and relieving factors bruits 2. Note circulatory sufficiency Associated symptoms 3. Bruits ■ Lower urinary tract and bowel symptoms ■ Examination of the hips, pelvis and spine ■ Sexual history (self assessment questionnaire 1. Note range of movement, local tenderness in can be useful and save time) (www.urologyedin- hip, pubic symphysis and sacroiliac joints burgh.co.uk/sexual_function_questionnaire.htm). 2. Straight leg-raising Examination Investigations ■ Lying and standing examination of the testis ■ Routine urine analysis (sugar, blood, protein), 1. Look for evidence of varicocele and hernia microscopy and culture 2. Size and tenderness of the testicles ■ Ultrasound examination 3. Transillumination 1. Testis ■ Rectal examination 2. Transrectal US 1. Note pain or tenderness or any other abnor- ■ Other procedures may include: mality (Chap. II.3.1) 1. CT or MRI scan ■ Peripheral nervous system – to exclude evidence 2. Exclusion of inguinal hernia, injection of of neuropathy contrast into the peritoneal cavity and a 1. Define any areas of hyperesthesia or any herniogram X-ray a areas of sensory loss 3. Cord block with bupivacaine has been 2. evidence of motor loss or wasting reported as a useful test to help select men 3. examination of reflexes suitable for microsurgical cord denervation a Pain distribution and sensory abnormality in chronic pain syndromes typically do not follow defined nerve territories. However, assessment is complicated by the variation in the course and cutaneous innervation territories of the ilio-inguinal and genitofemoral nerves. 174 I.7 Problem: Emergencies in Andrology

I.7.5.4 Local Nerve Blockade and Ablation Differential Diagnosis Local anaesthetic blockade of sympathetic ganglia is I.7.5.4.1 widely used in treatment of chronic pain conditions, Differential Diagnosis of Acute Testicular Pain but generally with mixed results (Chaturvedi and Dash The most important differential diagnosis of sudden 2001; Hord and Oaklander 2003). onset acute testicular pain is between torsion (see Hamza and Rowlingson (2004) reported a small se- Part I.7.1) and epididymo-orchitis. It is essential to ries in which superior hypogastric plexus block re- have a high index of suspicion for torsion in the youn- lieved pain in 12 of 14 men with chronic testicular pain, ger man who develops sudden acute testicular pain. If and Yamamoto et al. (1995) reported transrectal block- the differential diagnosis between torsion and epididy- ade of nerves of pelvic plexus to be superior to sper- mo-orchitiscannotberesolvedwithcertaintybyultra- matic cord nerve blockade in a further small cohort. sound (Dogra and Bhatt 2004), Doppler studies and Pulsed radiofrequency neurotomy has been used in clinical examination, or if there is likely to be delay in sacroiliac arthropathy (Ahadian 2004) and Cohen and undertaking these investigations, then it is best to un- Foster (2003) have published a case report of three men dertakeanexploratoryoperationtoexcludetorsion. with orchalgia who were pain-free at 6 months, but Even if an operation for suspected torsion reveals the none of these series provide strong evidence for effec- diagnosis of epididymo-orchitis, there is unlikely to be tiveness. At best, local nerve blockade may provide a any long-term harm, whereas failure to undertake ex- temporary window of relief during which to initiate ploratory operation and a missed diagnosis of testicu- other treatments. Levine and Matkov (2001) have advo- lar torsion results in the loss of the testicle. cated local anaesthetic block of the spermatic cord and an initial step to identify those likely to gain from microsurgical denervation. I.7.5.4.2 Intrathecal opioids and other medications have Differential Diagnosis of Chronic Testicular Pain been used in other intractable chronic pain states (Ka- and Chronic Testicular Pain Syndromes noff 1994), as have spinal cord stimulation (Grabow et This can be very difficult and depends on the androlo- al. 2003; Kemler et al. 2004; Forouzanfar et al. 2004), I.7 gist realizing all the possibilities, including causes of acupuncture, TENS and other similar techniques. To neuropathic pain and undertaking investigations as de- our knowledge, there are no reported evaluations so far tailed above to exclude any treatable cause. of the application of these techniques for chronic testicular pain. I.7.5.5 Treatment Surgical Intervention I.7.5.5.1 The place of surgical management in the context of Management of Chronic Testicular Pain (Orchalgia) chronic testicular pain remains a matter for debate. Surgical intervention is likely to work best for condi- Medication for Orchalgia tions where there is clear evidence of a surgically reme- In general, oral analgesia is not very helpful except in diable cause, such as primary pathology in the testis or the acute postoperative period after testicular surgery. scrotum, or clear evidence of actual nerve entrapment, It is worth noting that there are sex differences in re- which is likely to be relieved by decompression. Treat- sponse to analgesics in rodents (Terner et al. 2003; Mit- ments such as epididymectomy to remove a source of rovic et al. 2003) and in men (Fillingim 2002; Craft pain or denervation procedures have sometimes been 2003), and men respond better to opioid analgesics advocated,butasthepainnervepathwaysbecome than women; therefore household analgesics that may more and more facilitated, ablative procedures become have been prescribed for the female partner are not less and less likely to work and more and more likely to necessarily the best option. For established neuropath- amplify the pain. Although some success has been re- ic pain, oral medication with amitriptyline (Pilowsky ported following cord denervation operations, these and Barrow 1990; McQuay et al. 1992) and gabapentin aretypicallyinprivatepracticesettingswherethere (Gustorff et al. 2002) may help. GABA receptors are pre- may be surgical bias towards surgical solutions. The se- sent in the testis, vas deferens (Geigerseder et al. 2003) ries are generally small, and with only short-term fol- as well as the central nervous system (Naumenko et al. low-up.Therearenoproperlycontrolledrandomized 1996), and thus gabapentin may have an effect at sever- clinical trials in the literature for any of the procedures al levels. The effect of gabapentin on fertility is not described. known. Reportsofinterventionalproceduresfortesticular pain are listed in Table I.7.7. I.7.5 Testicular Pain and Related Pain Syndromes 175

Table I.7.7. Results of interventional procedures for chronic testicular pain Varicocele ligation Ribe et al. (2002) Improvement or resolution of pain in 22/25 men following subinguinal varicocele ligation Yeniyol (2003) Pain cured in 72/87 Maghraby (2002) Pain cured in 49/58 men following laparoscopic varicocele ligation Peterson et al. (1998) Pain cured in 30/35 men following surgical ligation Yaman et al. (2000) Pain cured in 72/82 men following microsurgical subinguinal varicocele ligation Reversal of vasectomy for post vasectomy pain Myers et al. (1997) Case series (n = 32): reports 75% relief after first reversal procedure plus a further10%aftersecondprocedure Nangia et al. (2000) Case series (n = 13): 69% pain-free Microsurgical denervation of the cord Levine and Matkov (2001) Complete pain relief in 25/33 testicles Selected on successful temporary spermatic cord block Heidenreich (2001); Heidenreich et al. Case series (n = 35): reports 97% success (median follow-up 31.5 months) (2002) Selected on successful temporary spermatic cord block Devine and Schellhammer (1978) Case report of two men Caddedu et al. (1999) Case series (n = 9). Laparoscopic denervation – pain relief in 7/9 (mean follow-up 25 months). Selected on successful temporary spermatic cord block Choa and Swami (1992) Case series (n = 4). Complete relief from pain immediately after surgery in all four cases (follow-up 2–36 months) Nerve decompression Shafik (2002) Case series (n = 4): Decompression of the pudendal nerve in the pudendal canal relieved pain within 1–3 weeks. Follow-up 9–14 months Orchiectomy (orchidectomy) Yamamoto et al. (1995) Three out of four men had pain relief after orchiectomy Negri et al. (2002) Case report of extraction and preservation of sperm in a man who had an orchiectomy. This is an option that should be considered for younger men I.7 It must be recognized that surgery in the context of or- except the testicular artery and main veins but includ- chalgia carries a significant risk that it will make mat- ing the vas deferens, whereas other surgeons may pre- ters worse rather than better. This should be fully dis- serve the vas deferens and lymphatics. The procedure is cussed with the patient and documented as part of the best undertaken using an operating microscope, espe- informedconsentprocedure.Itisalsoimportanttore- cially if lymphatics are to be preserved. It is wise to use member that patients with chronic pain are shown to a local anaesthetic field block with an anaesthetic such make poor decisions about risk (Apkarian et al. 2004) as levobupivacaine in addition to general anaesthesia, and this will be particularly relevant when considering so that when the man regains consciousness immedi- the risks and benefits of further surgery. ately following his operation he feels no pain. In addi- Operations that can be considered include: tion, it may be worth considering 6 weeks adjuvant postoperative gabapentin or amitriptyline; however, ■ Epididymectomy in cases of postvasectomy this is anecdotal practice and needs confirmation by chronic pain, and when on clinical examination clinical trial. At the 6-week postoperative review, the ga- there is localized severe tenderness in the epidi- bapentin can be stopped if the man has been pain-free dymis for at least 2 weeks; otherwise it should be continued. ■ Varicocele ligation when there is left-sided orchalgia ■ Microsurgical division of nerves in the cord to the Interdisciplinary Pain Management for Chronic testicle when the pain seems to be confined to the Testicular Pain Syndromes testicle Costabile (1991) reviewed records of 48 patients with Orchiectomy is not uncommonly used when all else chronic testicular pain. Between them, they had had fails, but there are very few reported case series in the 221 diagnostic procedures and 74 surgical procedures, literature to define its usefulness. in 80% of which only normal tissue was found. After Surgical denervation should probably be considered 8 years, 31 were available for interview, of which 29 only in cases where local anaesthetic blockade of the (93%) had pain unchanged. Schover (1990) assessed 48 spermatic cord has provided short-term relief (Levine men with genital pain and found that 56% met criteria and Matkov 2001). The operation of cord denervation is for somatization, 27% met criteria for major depres- not standardized; some surgeons divide all structures sion, and 27% were chemically dependent. It is clear 176 I.7 Problem: Emergencies in Andrology

from this background that surgery is more often than necessarily passive role. Sexual difficulties may place not a poor treatment choice. strain on partner relationships and in severe cases, ex- Once the diagnosis of a chronic testicular pain cessive time off work may lead to job loss and all its ac- seems probable and when there is no clearly defined companying disadvantages. Multiple hospital stays or pathology, management changes from trying to cure surgical procedures may alert the clinician to failure of the problem to helping the man come to terms with the previous well-intentioned medical interventions, and disabilityandtocopewithitasbesthecan.Inthecon- any history of litigation should be noted. text, management is best undertaken in a multidisci- Unremitting pain can be a distressing experience plinary fashion by the urologist and the pain manage- (Hendler 1984), which affects not only the patient ment team (Harden and Cole 1998). The components of (Kemler and de Vet 2000), but all others in the house- an interdisciplinary approach to management are sum- hold (Kemler and Furnee 2002). It is important there- marized in Table I.7.8. fore to recognize and address all the emotional and In the presence of unremitting pain, it is common psychosocial factors that contribute in each case for individuals to become physically inactive. Second- (Stanton-Hicks 1998; Harden and Cole 1998). These ary deconditioning may lead to reduced endorphin lev- may include: els and heighten the experience of pain. Well-meaning ■ Depression, anxiety and other mood disturbance family members may sometimes be oversolicitous in ■ Anger or bitterness relating to the cause of the their care and attention, and this can result in abnormal problem illness behaviour, with the individual adopting an un- ■ Fear about the underlying condition or about the future ■ Sexual and relationship difficulties Table I.7.8. Components of an interdisciplinary approach ■ Social consequences of the problem such as Medical management inability to work and financial problems Reassurance that there is no life-threatening underlying ■ Litigation or other legal proceedings cause and that increased physical activity will not be harmful The man should be encouraged to lead as normal a life Provide continued follow-up to prevent cure seeking else- as possible irrespective of his pain, and analgesics where and iatrogenic damage I.7 Support any litigation/compensation claim to its resolution shouldbegiveninthecontextofencouragingtheman and conclusion to go out and about and work normally. The rationale Education istotrytodistractthefocusofattentionfromthe Explain how emotional stress and deconditioning can in- pain. crease symptom experience Litigation procedures may be drawn out over a long Provide insight into how their own behaviours may serve to period and may delay resolution of the pain because exacerbate their symptoms the man’s attention is focused on the problem and its Help patient to understand and accept a self-management approach perceived cause. In some cases, it may be appropriate to Teach relaxation techniques, breathing exercises, etc. to re- work proactively with the individual and his legal advi- verse sympathetic arousal sors to bring litigation to an early conclusion and allow Psychiatry and psychology him to move on. Identify any psychological factors contributing to excessive symptoms and illness behaviours Monitor mental state and undertake risk assessment for I.7.5.6 self-harm Results of Treatment Treat anxiety and depression (consider psychotropic drug management if necessary) In general, if the diagnosis is chronic testicular pain, Teaching coping strategies, positive thought patterns to then the results of interventional treatments are rea- help them regain control and inhibit negative thoughts, catastrophizing, etc. sonable, but if the diagnosis is a chronic testicular Identify and challenge secondary gain resulting in excessive pain syndrome, then interventional treatments may illness behaviour make the problem worse. Unfortunately, there is no Identify maladaptive family behaviours and support family sure way other than clinical acumen to differentiate in encouraging individual to relinquish their sick role the conditions, and because of this difficulty most and do more for themselves treatment series report failure rates of between 20% Physical and occupational therapy and 50% (Gray et al. 2001) (Table I.7.7). Higher suc- Progressive increase in physical activity and reconditioning to build up cardiovascular fitness cess rates have been reported after microsurgical de- Encourage recreational physical exercise and functional nervation procedures provided that cases are selected goals on the basis of a good response to a local anaesthetic Supportedreturntosocial,recreationalandvocational nerve block. activities as appropriate I.7.5 Testicular Pain and Related Pain Syndromes 177

Craft RM (2003) Sex differences in drug- and non-drug-in- I.7.5.7 duced analgesia. Life Sci 72:2675–2688 Prognosis Devine CJ, Schellhammer PF (1978) The use of microsurgical denervation of the spermatic cord for orchialgia. Trans Am I.7.5.7.1 Assoc Genitourin Surg 70:149–151 Prevention Dogra V, Bhatt S (2004) Acute painful scrotum. Radiol Clin North Am 42:349–363 Prevention of Chronic Testicular Pain Dunn D (2000) Chronic regional pain syndrome, type 1: Part I. AORN J 72:422–32, 435–449; quiz 452–458 Prevention of chronic pain syndromes is an important Fillingim RB (2002) Sex differences in analgesic responses: evi- aspect of all scrotal surgery. There is some evidence dence from experimental pain models. Eur J Anaesthesiol that chronic pain is more likely to be triggered if there Suppl 26:16–24 is pain in the immediate postoperative period. 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