Daniel H. Williams, IV, MD
Series Editor Christopher M. Gonzalez, MD, MBA
Dr. Williams is associate professor of urology, obstetrics and gynecology, residency program director, and director of male reproductive medicine and microsurgery at the University of Wisconsin School of Medicine and Public Health, Madison. Series Editor Christopher M. Gonzalez, MD, MBA, is professor of urology at Northwestern University's Feinberg School of Medicine, Chicago.
Chronic orchialgia, orchidynia, epididymalgia, epididymitis, scrotalgia, scrotal content pain, scrotal pain syndrome, testicle pain, groin pain—call it what you wish. The constellation of symptoms in this heterogeneous patient population is as variable as the terms used to describe it. Regardless of the label, this condition can be very frustrating for patients to live with and equally frustrating and challenging for clinicians to manage.
The European Urological Association (EAU) uses the generic term “scrotal pain syndrome” to include testicular pain syndrome, post-vasectomy pain syndrome, and epididymal pain syndrome (Eur Urol 2010; 57:35-48). EAU guidelines cover the diagnosis, treatment, and follow-up of patients with these conditions. A multidisciplinary approach including physiotherapy is recommended.
While guidelines can be useful to help direct patient care, each patient’s situation needs to be individually tailored, and care should be offered based on symptoms and response to prior therapy. This article reviews the evaluation and the medical and surgical management options for patients with what most experts refer to as chronic scrotal content pain.
Symptoms and impact on QoL
Symptoms of scrotal pain syndrome may be dull and throbbing. Pain can be unilateral or bilateral in the scrotum and may change throughout the day. The pain may be stabbing or shock-like. It may radiate to the perineum and the inner thigh. It may worsen with certain physical activities including sitting, driving, cycling, or sexual activity. There can be hypersensitization of the skin, such that even the presence of overlying clothing might exacerbate the problem.
An early definition of chronic scrotal content pain, from Davis et al, describes intermittent or constant symptoms that can be unilateral or bilateral. The duration of the symptoms is generally greater than 3 months and the pain significantly interferes with daily activities (J Urol 1990; 143:936-9).
Scrotal pain can have a significant impact on quality of life and can result in behavioral changes and modifications, as well as changes in sexual behaviors such as avoidance of sexual activity that may impact not only the man but his partner. Scrotal pain carries with it a significant burden of medical costs. In a Swiss study, the incidence of scrotal pain was approximately 350 to 450 per hundred thousand men between the ages of 25 and 85 years, representing 6.5 new urology patients per month and equating to approximately 2.5% of all medical care visits (Eur Urol 2005; 47:812-6).
The innervation of the urogenital system as it applies to chronic scrotal content and chronic groin pain typically is that of the iliohypogastric nerve, the ilioinguinal nerve, and both the genital and femoral branches of the genital-femoral nerve.
Nociceptive pain refers to direct stimulation of the nociceptors in the periphery. This type of pain would be the normal and expected response resulting from a painful stimulus. Neuropathic pain arrives not from the affected area but is rather due to a lesion either in the central or peripheral nervous system. Allodynia is the magnification of the perception of the pain so that a non-painful stimulus is perceived as being painful. Hyperalgesia describes a more painful perception than what would typically be expected. Neuromodulation refers to increasing afferent nerve signals that can result in a change from a non-noxious sensation into a noxious one. Reproductive and other pelvic organs are encoded for both noxious and non-noxious stimuli.
When acute pain (quick onset and short lived) turns into chronic pain lasting greater than 3 months, changes can occur in the central nervous system that maintain the perception of pain even in the absence of injury. This plasticity of the central nervous system adds to the challenges and frustrations of adequately treating pain syndromes.
Causes of chronic testicular scrotal content pain can include post-vasectomy pain syndrome, trauma, previous surgery (including herniorrhaphy, hydrocele repair, and varicocelectomy), tumor, post-infection pain, post-torsion pain, as well as neuropathic pain, imipramine withdrawal, and polyarteritis nodosa. Chronic testicular scrotal pain may also be idiopathic in origin (Ned Tijdschr Geneeskd 2005; 149:2728-31).
Causes of chronic non-testicular scrotal content pain can include spermatocele, hydrocele, and varicocele. Pain may also be related to epididymitis, including acute bacterial epididymitis as well as non-bacterial infectious epididymitis from viral syndromes, as well as non-infectious epididymitis such as idiopathic traumatic autoimmune or amiodarone-induced epididymitis (Ned Tijdschr Geneeskd 2005; 149:2728-31).
An important cause of scrotal content pain that must remain in the diagnostic and treatment algorithm is musculoskeletal etiology. There are multiple pelvic and lower-extremity muscles that attach to and are intertwined with the bony pelvis. The insertion points of the adductor muscles and the gracillus muscle are often the region of the reported scrotal content pain. The spermatic cord is intimately connected to the muscles of the internal oblique and transversus abdominus. Pelvic, scrotal, and inguinal pain may be due to musculoskeletal causes, particularly when tenderness localizes to the areas of insertion of these muscles or when pain is elicited and reproduced with certain movements. Tenderness on palpation of the pubic symphysis may be due to osteitis pubis
Men may also have pain due to sports hernias, which can be found with local tenderness over the conjoint tendon, the pubic tubercle, or the mid-inguinal region. Treatment of musculoskeletal causes of scrotal content pain is generally best handled by physical therapists with specialized training in the pelvic muscles.
Pain that patients perceive in the scrotal area may also be due to referred pain. Men may have chronic pelvic pain syndrome or pelvic floor muscle pain syndrome. A ureteral calculus may refer pain to the inguinal region and genitalia, particularly if it is a distal stone. Retroperitoneal masses may cause referred pain to the genitalia. Patients may also suffer from neuropathy due to pudendal pain syndrome or from ilioinguinal nerve entrapment following inguinal hernia repairs.
It is important to first rule out any harmful or clearly treatable cause of scrotal content pain. Identify and rule out testicular torsion, infectious or inflammatory causes, malignant causes, and trauma. These entities are relatively easy to diagnose and treat.
The evaluation of chronic scrotal content pain includes taking an appropriate medical history and asking about other chronic pain conditions. It is important to elicit if there are any specific triggers to the pain or if there are any associated voiding symptoms, as chronic scrotal content pain may also be related to chronic prostatitis and the chronic pelvic pain syndrome. A history of vasectomy poses a unique set of diagnostic and therapeutic challenges that will be described below.
A focused and detailed physical examination of the genitalia is critical in the evaluation of chronic scrotal content pain. It is of utmost importance to identify the specific pain location, as this can ultimately help guide both medical and surgical treatment options. A digital rectal examination should be performed not only to check for any prostate pathology but also to examine the pelvic floor muscles for musculoskeletal dysfunction. If examination of the scrotum, inguinal region, or prostate reproduces the pain, this is important to note as well. A neurologic examination is important to help identify which specific nerve distribution is affected.
In the evaluation of any chronic pain syndrome, it is notable to consider psychological evaluation, as there seems to be a high association between pain syndromes and depression and anxiety. Men with chronic scrotal content pain may also carry addictive personalities and demonstrate alcohol, drug, and tobacco abuse. A more difficult and sensitive topic to broach with chronic pain syndromes is any history of emotional, physical, or sexual abuse.
Other components of the evaluation include obtaining a urinalysis and culture, and when applicable, testing for sexually transmitted infections. Obtaining a semen culture may be considered but typically is of limited value. In contrast to EAU guidelines, the author favors obtaining a duplex scrotal ultrasound to rule out any obviously treatable or concerning scrotal pathology, especially when the patient exhibits voluntary or involuntary guarding, or when the patient is too uncomfortable, making a valid physical examination difficult to perform. While duplex scrotal ultrasounds generally do not reveal underlying causes of chronic scrotal content pain, seeing normal ultrasound images of the testes helps to reassure patients that they do not have worrisome scrotal pathology such as cancer. A scrotal ultrasound should be performed when a palpable abnormality is detected on physical examination or if it is not possible to adequately examine the patient due to pain or guarding.
Additional radiographic imaging for the evaluation of chronic scrotal content pain generally is quite expensive and often of low yield.
A diagnostic algorithm for scrotal content pain is shown in figure 1.
Treatment: Medical therapies
Once any treatable or harmful cause of chronic scrotal content pain has been ruled out, the next step is to offer therapy. Medical therapy for the treatment of chronic scrotal content pain is challenging and typically empirical. Antibiotics can be prescribed initially if an infectious etiology is suspected.
Nonsteroidal anti-inflammatory drugs can be offered should there be an inflammatory component of the pain syndrome. However, a recurrence rate of up to 50% has been shown even when these medications are given in combination with antibiotics (Eur Urol 2005; 47:812-6). Opiate medications may be used for breakthrough pain.
There may be a role for antidepressant and anticonvulsant medications. In one study, approximately two-thirds of patients reported a greater than 50% improvement in their scrotal content pain with nortriptyline (Aventyl, Pamelor) and gabapentin (Neurontin) (Int J Urol 2007; 14:622-5). An interesting finding of this study was that these medications were much more effective in treating idiopathic chronic scrotal content pain than post-vasectomy pain syndrome.
When the chronic scrotal content pain is found in combination with chronic prostatitis or the chronic pelvic pain syndrome, then pelvic floor physical therapy should be offered. Chronic bacterial or inflammatory prostatitis may be detected by evaluating expressed prostatic secretions for white blood cells or bacteria. There may also be a role for acupuncture in the care of such patients (Urology 2003; 61:1156-9; discussion 9).
Non-surgical therapies for chronic scrotal content pain can also include scrotal support, sitz baths, and local/regional nerve blocks. There are limited reports of the utility of pulsed radiofrequency (Urology 2003; 61:645; Pain Med 2009; 10:673-8). Lastly, many patients will benefit from emotional and psychological support with psychotherapy, particularly when other medical or surgical management strategies fail (J Urol 1991; 146:1571-4).
In summary, treatment is often empirical and based on any identifiable etiology if present. Medical therapy should be offered to men with chronic scrotal content pain prior to surgical management. Surgical therapy, as outlined below, is indicated when non-surgical options fail. A treatment algorithm for chronic scrotal content pain is shown in figure 5.
Surgery for scrotal content pain can include surgery for identifiable scrotal pathology such as varicocelectomy, hydrocelectomy, spermatocelectomy, and orchiectomy for a testis mass. Vasectomy reversal and epididymectomy can be utilized for post-vasectomy pain syndrome. Neurectomy procedures and orchiectomies are also surgical options.
To help determine whether or not a patient is a candidate for surgical management, a spermatic cord block can be offered. A properly performed spermatic cord block can determine if pain signals are traveling via the spermatic cord. It has been demonstrated that a positive spermatic cord block result can correlate to surgical success with microsurgical denervation (J Sex Med 2013; 10:876-82).
The block can be performed with a combination of half 1% lidocaine and half 0.25% bupivacaine (both without epinephrine), typically injecting 10-20 mL. Hold the spermatic cord with the non-dominant hand, and using a control syringe and with the vas deferens as a landmark, inject into the spermatic cord, usually at the level lateral and inferior to the penis and superior to the testicle.
Microsurgical denervation of the spermatic cord was introduced in 1978 with a case report of two patients (Trans Am Assoc Genitourin Surg 1978; 70:149-51). The concept of this procedure is to allow sparing of the testicle with physiologic and psychological benefits. There is a low side effect profile of this treatment and, to date, no de novo hypogonadism has been reported. Cure rates for microsurgical denervation of the spermatic cord range from 70% to 97%, and this procedure can be offered after failed prior surgery, with an approximately 50% pain-free rate after varicocelectomy, vasectomy reversal, or hernia repair (J Urol 2013; 189:554-8).
Steps of microsurgical denervation of the spermatic cord include making a small sub-inguinal incision and delivering the spermatic cord into the operative field (figure 2). With the operating microscope, arteries and lymphatics are identified and spared (figure 3). All other structures, including the vas deferens, are ligated with sutures and/or electrocautery (figure 4). If a man wishes to preserve his fertility potential, the procedure may be performed with a vas deferens-sparing approach. However, this approach may yield inferior outcomes for pain control as sensory nerves do travel through the vas deferens.
Other denervation procedures include tri-neurectomy, laparoscopic, and robotic approaches. The tri-neurectomy approach as a primary treatment following pelvic surgery or hernia repair has been reported to have an 85% to 90% success rate (J Am Coll Surg 2011; 213:531-6). The laparoscopic approach includes division of the gonadal vessels with associated nerves cephalad to the internal ring (J Urol 1999; 162[3 Pt 1]:733-5; discussion 5-6). The robotic approach has shown an 85% rate of patients reporting significant decrease in their pain (Curr Opin Urol 2011; 21:493-9).
Epididymectomy can be a surgical consideration for chronic scrotal content pain. This procedure is indicated when the pain involves and localizes to the epididymis only. This procedure can be especially useful when a painful cyst or mass is present or when scrotal ultrasound demonstrates a structural abnormality within the epididymis. This approach is not typically useful to treat pain secondary to chronic inflammation. Cure rates in the literature range from 11% to 59% (J Urol 2009; 182:1407-12; J Urol 1996; 156:95-6; Br J Urol 1998; 81:753-5).
A unique subset of chronic scrotal content pain is in patients with post-vasectomy pain syndrome. It is estimated that chronic pain is present in 1% to 15% of men following vasectomy (Ned Tijdschr Geneeskd 2005; 149:2728-31), with severe scrotal content pain being reported in 1% to 6% (BJU Int 2007; 100:1330-3). While the true etiology of post-vasectomy pain syndrome remains unknown, it is thought to result from the functional obstruction of the vas deferens, spermatic granuloma formation, and/or chronic idiopathic epididymitis. Vasectomy reversal is a surgical option for post-vasectomy pain syndrome. Most of the published literature is from small, single-center studies, with success rates ranging from 75% to 100% improvement in pain and 50% to 69% being pain free (J Urol 2012; 187:613-7; J Urol 1997; 157:518-20; J Urol 2000; 164:1939-42; Fertil Steril 1979; 32:546-50). Other surgical treatments for post-vasectomy pain syndrome include orchiectomy (radical orchiectomy would be required), open-ended vasectomy, epididymectomy, and microsurgical denervation of the spermatic cord (J Urol 2008; 180:949-53).
Chronic scrotal content pain is a common disorder with significant social and economic burden. The initial step of the evaluation and management of these patients is to localize the pain and assess for an underlying treatable cause. Medical therapies remain the first-line treatment, and surgical treatments can be effective in appropriate patients who fail medical management.UT
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