Orchialgia or chronic scrotal pain syndrome = pain or discomfort, arising from testis/epididymis/cord, intermittent or constant, lasting at least 3 months, and interfering with quality of life.
Anatomical considerations
Testis innervation:
- All sympathetic, arising from T10 – T11, coursing along with gonadal vessels
- Overlying tunica vaginalis and surrounding cremaster supplied by genital branch genitofemoral nerve which runs in cord
Scrotum innervation
- Anterior wall innervated by branches of ilioinguinal nerve (L1) and genital branch of genitofemoral nerve
- Posterior wall innervated by scrotal branches of perineal nerve from pudendal nerve (S2-S4), and branches of posterior femoral cutaneous nerve
Epidemiology
2 – 5 % of clinic visits in Europe.
Most commonly 20 – 30 years old.
Causes
Acute pain different from chronic pain – ensure acute causes (torsion) considered if appropriate.
| Urological | Abdominal/Retroperitoneal | Musculoskeletal | Idiopathic |
| Hydrocele
Epididymal cyst Varicocele Tumour Prostatitis Chronic epididymitis Retractile testis Post vasectomy pain |
Ureteric stone/ obstruction
Hernia (pressing on GFN) IBD Retroperitoneal mass Aneurysm (AAA, CIA) Ilioinguinal nerve injury |
Hip pathology
Spinal pathology Pelvic floor dysfunction Abdo wall muscles |
Idiopathic
40 – 50 % |
Work-up / assessment
History:
- Pain history
- Exacerbating / relieving factors
- Radiation of pain / other sites
- Change with pelvic functions (urination, bowels, ejaculation)
- Palpable changes
- Current and prior treatments and specialists
- Medical history (urological, psychological, orthopaedic) and medications
- Surgical history (hernia, vasectomy, scrotal, abdominal)
- Social history – partner, previous abuse, children/plans
Examination:
- Good communication
- Abdominal and inguinal areas
- Penile plaque, perineal tenderness
- Scrotal exam – bilaterally, feeling for testis/epididymis/vasa and trying to localise pain
- DRE including pelvic floor and prostatic tenderness
Investigations:
- Urine microscopy / culture
- STI testing if risks
- Scrotal ultrasound (often done prior to referral)
- Musculoskeletal imaging as needed (MRI spine, US/XR hips)
- Abdominal imaging as needed (stones, hernia, retroperitoneal causes)
Spermatic cord block can be considered part of investigations as is more so diagnostic than therapeutic (although can offer relief sometimes, “breaking the cycle”).
- 5 – 20 mL of 0.25 % bupivacaine into cord overlying the pubic tubercle
- > 50 % relief in pain predicts response to operative treatment
- Direct patients to go and do things which exacerbate the pain.
- Pain may come back worse (counsel appropriately), < 5 % risk haematoma
Management
Should be multidisciplinary, with pain specialists, physio, psychology, others as needed.
Patients often frustrated, tried many things and seen many doctors.
Education, empathy, and accept need for possible trials of different treatments.
Aim is often to improve quality of life rather than cure.
Conservative:
- Nonpharmacological management – tight underwear, icepacks/warm compresses, warm baths
- Pelvic physiotherapy +/- musculoskeletal assessment
Simple oral options
- Course of anti-inflammatories
- Antibiotics have often been tried prior and the cause is often non infective.
- Some anti-inflammatory properties of quinolones
- Reasonable for trial if epididymitis or STI suspected but probably no benefit of prolonged courses of fluoroquinolones
- Alpha-blockers or PDE5 inhibitors if indicated
Complex oral options
- Neuropathic pain agents
- Amitriptyline nocte 25 mg – some noradrenaline reuptake inhibition
- Pregabalin (Lyrica)
- Consider cardiac side effects, involve chronic pain specialist
Minimally invasive options
- Pulsed RFA of spermatic cord or of genitofemoral and ilioinguinal nerves
- Transcutaneous electrical stimulation
- Acupuncture
- Series of spermatic cord blocks
- Botox to spermatic cord
Surgical options
- Treatment of underlying cause – hydrocele, epididymal cyst, varicocele.
- Epididymectomy for chronic pain localised to the epididymis – may have poor outcomes with persistence of pain, patients need to be appropriately counselled
- Microsurgical spermatic cord denervation
- Orchidectomy – inguinal approach may have slightly better outcomes
- Vasectomy reversal – in pain thought to be from obstruction post vasectomy
- Division of cremasteric muscles for painful retractile testis
Microsurgical spermatic cord denervation
- Spermatic cord neuroanatomy has been defined with ‘trifecta’ nerve complex
- Cremasteric fibres
- Perivasal
- Posterior lipomatous
- > 50 % improvement in pain with spermatic cord block portends good response
- Microscopic or robotic
- Subinguinal incision and exposure of cord over Penrose drain or similar
- Division of ilioinguinal nerve
- Stripping of perivasal tissue
- Preservation of lymphatics
- Division of all cremasteric fibres
- Complications:
- Testicular atrophy 1 – 2 %
- Wound infection
- Hydrocele
- Penile or scrotal oedema
- Haematoma