Joel J. Heidelbaugh, MD, FAAFP; Mikel Llanes, MD; An algorithm for the treatment William J. Weadock, MD Departments of Family of chronic testicular pain Medicine (Drs. Heidelbaugh and Llanes), Urology 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 scrotum 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 chlamydia with either a a vasectomy 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 hematospermia. Recently, the pain has PAIN single dose (1 g) of azithromy- TREATMENT cin; treat suspected gonorrhea 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/scrotal ultrasound 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 –epididymitis Empiric trials: –prostatitis • 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. –inguinal hernia If no satisfactory response: –nephrolithiasis Consider tricyclic antidepressant or gabapentin – nerve entrapment (eg, ilioinguinal, titrated to achieve maximal therapeutic benefi t genitofemoral) –spermatocele –testicular or appendiceal torsion If no satisfactory response: –tumor • Consider psychiatry referral –varicocele • 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 testicles, 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 palpation through- • Acute appendicitis 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, varicoceles, or hydroceles; testicular, • Lumbosacral radiculopathy scrotal, or penile lesions; inguinal masses; or • Orchitis (eg, mumps) lymph nodes. His urethral meatus is patent. • Testicular cancer The prostate is smooth, nonnodular, and non- tender. The remainder of the physical exam is • Testicular torsion/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 testicle, 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 gangrene 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%, • Hydrocele 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/pelvis 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) epididymis (FIGURES 2A AND B). Epididymal cysts are common fi ndings 332 THE JOURNAL OF FAMILY PRACTICE | JUNE 2010 | VOL 59, NO 6 CHRONIC TESTICULAR PAIN FIGURE 2 Well-circumscribed extratesticular mass A B IMAGES COURTESY OF: WILLIAM J. WEADOCK, MD IMAGES