Diagnosis and Surgical Management of Male Pelvic, Inguinal, and Testicular Pain a b, Gabriel V. Belanger, MD , Graham T. VerLee, MD * KEYWORDS Pelvic pain Inguinodynia Orchalgia KEY POINTS Pain in the prostate follows a continuum from acute to chronic, and treatment can be complicated by poor penetration of antibiotics into the reproductive tract. Inguinal pain occurs most commonly in the context of a previous herniorrhaphy. First-line pharmacotherapy should include gabapentinoids and tricyclic antidepressants, rather than opioids. Orchalgia and scrotal pain should prompt an ultrasonography scan to rule out acute disorder. Although promising surgical approaches exist to treat chronic scrotal pain, their success depends in part on intervening before central sensitization has occurred. INTRODUCTION Pain occurs in the male genitourinary organs, as for any organ system, in response to traumatic, infectious, or irritative stimuli. There are several hypothetical instances in which a knowledge and understanding of chronic genitourinary pain can be of great utility to practicing nonurologists, especially in clinical settings in which urologic consultation services are scarce or not readily available. Naturally, genitourinary pain should initially be regarded as a symptom of a possible underlying disorder, and every effort should be exerted to identify an organic source, but, when a pertinent causative disorder is effectively excluded from the differential diagnosis, chronic pain then becomes its own diagnosis. Chronic pain in the male genitourinary system is a distressing complaint for the patient, with only subtle objec- tive anatomic and microanatomic findings, if any, and effective treatment options until Disclosure: The authors have nothing to disclose. a Division of Urology, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA; b Maine Medical Partners Urology, 100 Brickhill Avenue, South Portland, ME 04106, USA * Corresponding author. E-mail address: [email protected] Surg Clin N Am 96 (2016) 593–613 http://dx.doi.org/10.1016/j.suc.2016.02.014 surgical.theclinics.com 0039-6109/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved. 594 Belanger & VerLee recently have been limited.1 This article demystifies the causes of genital pain and re- views the current approaches to treatment in three regions of the male genital tract commonly affected by chronic pain: the prostate, the inguinal region, and the scrotum. CHRONIC PAIN PATHOPHYSIOLOGY Genitourinary pain may be regarded as having either a neuropathic or a nociceptive cause. The term neuropathic pain implies that the peripheral nerves are involved in the primary disorder or have been directly damaged by infection, trauma, or surgery. The resultant pain usually develops in the sensory distribution of the affected periph- eral nerve or nerves, and although the original insult has healed, the neurons acquire a pathologic level of activity to autonomously generate impulses in the absence of a stimulus.2 In contrast, non-neuropathic pain might include that of a persistent somatic nociceptive source, including inflammation of a wound, keloid formation, mass effect from aberrant anatomy such as a recurrent hernia, a foreign body such as a metallic vasectomy clip, or a chronic infection of the prostate or genitalia. There is evidence that additional pathophysiologic processes also contribute to the evolution of chronic pain, including neuroplasticity, afferent hypersensitivity, pain centralization, and deaf- ferentation hypersensitivity, which if present may predispose a patient to treatment failure even if a neuropathic or nociceptive source is identified and corrected.3 Several hypotheses exist for the emergence of chronic pain, and these theories are not mutually exclusive. There is evidence that the peripheral and central nervous sys- tems undergo a form of modulation following a long duration of painful stimuli, result- ing in sensitization of the pain receptors.4 Other evidence suggests that, as peripheral nerves regenerate following injury, axons may rejoin erroneously with one another in the dorsal spinal cord such that a depolarization detected by an axon might propagate its signal to an inappropriate neuron proximally, and thus innocent stimuli may be perceived as inordinately noxious.5 PROSTATIC PAIN The term prostatitis refers to a broad array of disease processes. The National Insti- tutes of Health (NIH) developed a classification system for prostatitis in 1995 and pro- posed universal adoption at the International Prostatitis Collaborative Network workshop in 1998, in Washington, DC6 (Table 1). CATEGORY I: ACUTE BACTERIAL PROSTATITIS Clinical Presentation Prostatitis is a common genitourinary infection, with a lifetime prevalence of up to 16%.7 A proposed cause of acute bacterial prostatitis (ABP) involves the reflex of Table 1 NIH prostatitis classification system Category Type I Acute bacterial prostatitis II Chronic bacterial prostatitis III Chronic prostatitis/chronic pelvic pain syndrome IIIA Inflammatory IIIB Noninflammatory IV Asymptomatic inflammatory prostatitis Male Pelvic, Inguinal, and Testicular Pain 595 infected urine into the ejaculatory and prostatic ducts of the prostatic urethra. Other possible routes of infection include invasion of rectal bacteria through direct extension or hematogenous spread.8 Iatrogenic causes include cystoscopic manipulation of the prostate or bacterial seeding via transrectal biopsy.9 Risk factors for ascending infec- tion include unprotected sexual intercourse, phimosis, indwelling catheter, and instru- mentation. Anything leading to urinary stasis, such as distal urethral stricture and benign prostatic hyperplasia, is also a risk factor.10 By definition, ABP has a rapid onset. Patients typically present with a combination of pelvic pain and lower urinary tract symptoms (LUTS). The pain is often described as pelvic, perineal, genital, or a combination.11 In addition to pain, patients may show a wide array of lower urinary tract symptoms. Symptoms may be irritative (urgency, frequency) or obstructive (weakened stream, intermittent stream, acute urinary reten- tion). Patients may also have dysuria. High-grade fever and other signs and symptoms of systemic illness are often present.11 In a retrospective analysis of 614 patients diagnosed with ABP by Milan and col- leagues,12 the most common complications in these patients were acute urinary reten- tion (9.7%), prostatic abscess (2.7%), and recurrent infection (12.7%). Patients with ABP secondary to genitourinary tract manipulation also fared much worse overall. Specifically, the investigators noted a higher risk of prostatic abscess, recurrent infec- tions, and infections involving atypical organisms in this group. Patients with ABP are at significant risk of progressing to chronic bacterial prostatitis (CBP).13 Diagnosis Unlike chronic prostatitis, ABP is diagnosed primarily by clinical history, physical ex- amination, and urine culture alone. Given the interconnectivity of the genitourinary tract, a complete urologic physical examination should be performed, including cost- overtebral angle percussion and palpation of the abdomen, bladder, testicles, and epididymides to rule out associated infectious/inflammatory processes.11 A gentle palpation of the prostate should be performed as well. The prostate is often described as being tender to palpation and often warm and boggy.14 Vigorous prostatic mas- sage should be avoided because of the theoretic risk of bacteremia.14 Therefore, the 2-glass and 4-glass tests used in the diagnosis of chronic prostatitis should be avoided (discussed later). Urine cultures generally grow out typical uropathogens, with Escherichia coli iso- lated up to 87% of the time. Other organisms include Pseudomonas, Serratia, Klebsi- ella, and Enterobacter.10 Chlamydia trachomatis is rarely isolated.15 Recent literature has shown an increasing prevalence of fluoroquinolone-resistant and extended- spectrum b-lactamase–producing bacteria in all patients with prostatitis, but espe- cially in those with prostatitis associated with transrectal prostate biopsy.16,17 Treatment Medical If the patient is febrile or systemically ill, treatment should be with a high-dose, broad- spectrum parenteral antibiotic, such as a broad-spectrum penicillin derivative, third- generation cephalosporin, or a fluoroquinolone until fevers and systemic symptoms have resolved.11 When clinically stable, the condition can be treated with oral fluoro- quinolone or trimethoprim/sulfamethoxazole, if tested susceptible.18 Treatment dura- tion of 4 weeks is recommended.19 Along with treatment of the causative organism, medical management directed at patient symptoms should be considered. Treat concomitantly with nonsteroidal anti- inflammatory medicines for symptomatic pain relief.18 Treatment with a-blockers has 596 Belanger & VerLee been shown to improve LUTSs in men with prostatic inflammation and should be considered in men in whom LUTSs are an issue.20,21 Temporary catheterization may be necessary to relieve acute urinary obstruction. Surgical Most patients who present with ABP are adequately treated with medical therapy alone; however, a small subset of patients require surgical intervention. In patients who fail to respond rapidly to medical therapy, consider transrectal ultrasonography or computed tomography scan to assess for abscess.22 Prostatic abscesses smaller than 1 cm can be treated conservatively with antibiotics, whereas larger abscesses benefit