Aug. 27, 2019
Matthew (Matt) J. Ziegelmann, M.D., a urologist at Mayo Clinic's campus in Rochester, Minnesota, focuses on men's health and male sexual dysfunction.
Scrotal pain is a frequent presenting complaint in the primary care setting. It accounts for up to 5% of outpatient urology visits. Despite this, chronic scrotal content pain (CSCP) remains a poorly understood condition. CSCP, also referred to as chronic orchialgia or testicular pain syndrome, is persistent pain (lasting at least three months) that is localized to the testicle, epididymis and spermatic cord and interferes with a patient's quality of life.
Currently, there are no standardized guidelines for evaluation and management of this condition. Therefore, a general understanding of CSCP is necessary to ensure that patients receive efficient and timely care.
What etiologies underlie CSCP?
A variety of conditions present with more-acute scrotal pain, including epididymo-orchitis, scrotal cellulitis, trauma and testicular torsion. Hydroceles, spermatoceles, varicoceles and testicular tumors may also present with pain. Referred pain from abdominal and pelvic organs is another important consideration; examples include inguinal hernia, obstructing ureteral calculus, vascular aneurysm, retroperitoneal mass, and hip and spine pathology.
Another entity, known as post-vasectomy pain syndrome and characterized by severe persistent scrotal pain, is estimated to impact 1% to 2% of patients. Finally, pelvic floor dysfunction (chronic pelvic pain syndrome or pelvic floor tension myalgia) may also present with CSCP.
Symptoms suggesting pelvic floor dysfunction include bilateral pain, pain with urination or ejaculation, perineal or suprapubic pain, and pelvic floor tenderness on exam. Notably, even after an exhaustive evaluation, no obvious contributing etiology is found in 35% to 45% of patients.
What is the initial evaluation for a patient presenting with CSCP?
Evaluation for a patient presenting with CSCP
The first step is a thorough history and physical exam. Pain location, radiation to surrounding areas, severity, and exacerbating and relieving factors are all important to understand. A thorough examination of the genitalia is mandatory, with careful inspection of the testicle, epididymis and spermatic cord, along with evaluation of the pelvic floor (digital rectal exam).
Adjunctive testing including a urinalysis, scrotal ultrasonography, plain films of the hip and spine, or cross-sectional imaging of the abdomen and pelvis may be ordered at the evaluating clinician's discretion.
How effective is the spermatic cord block as a diagnostic tool?
One of the most important diagnostic tools is the spermatic cord block, used to localize the source of the pain to the scrotal contents (the distribution of pain fibers from the spermatic cord). A spermatic cord block is indicated in the absence of an obvious alternative source for the pain. Local anesthetic is administered into the spermatic cord at the level of the ipsilateral pubic tubercle. The technique is described in a study published in the Journal of Sexual Medicine in 2018. It can be done easily in the office at the time of the consultation if so desired.
Significant improvement or complete pain relief with the block suggests that afferent signaling from nerve distributions within the spermatic cord are responsible for the pain. In most circumstances, the patient will experience pain recurrence within several hours, although on rare occasions the benefit may be prolonged. If there is minimal pain relief, other etiologies should be strongly considered. Some experts utilize a series of placebo (saline) controlled blocks to rule out malingering, which is rare.
How is idiopathic CSCP treated?
Data surrounding treatment options for idiopathic CSCP is limited. Repeated or prolonged antibiotic courses should be avoided as they are rarely helpful and prolong the interval to definitive treatment. Chronic opioid use should be avoided.
Sitz baths and anti-inflammatories are often used as first line therapy. As noted in studies published in the International Journal of Urology in 2007 and the World Journal of Men's Health in 2017, some authors have found modest success with off-label use of antidepressants (nortriptyline, amitriptyline) and anticonvulsants (gabapentin). In those patients who respond well to the diagnostic spermatic cord block, a series of blocks using a local anesthetic combined with a steroid may also be considered.
Men with evidence of chronic pelvic pain or pelvic floor tension myalgia should be referred for pelvic floor therapy, as noted in a study published in the Canadian Journal of Urology International in 2016. Alternative treatments such as spinal cord stimulators, transcutaneous electrical stimulation, scrotal vibration and even acupuncture have been studied as well.
Surgery represents an effective treatment modality for many patients with CSCP. The key lies in patient selection and is determined by history, examination and most importantly by a positive response to the spermatic cord block. In those men with pain isolated to the epididymis, epididymectomy may result in pain improvement or resolution for 75% to 90% of men.
If the pain is more diffuse and involves other scrotal structures, then microdenervation of the spermatic cord is considered the surgical treatment of choice. The procedure is performed with the aid of an operating microscope through a small inguinal incision and involves transection of the autonomic and somatic nerve branches within the spermatic cord.
A robot-assisted approach has been popularized as well. In appropriately selected patients, durable pain improvement rates approach 90% with complete resolution seen in up to 70%.
Are there any complications associated with surgery for CSCP?
While rare, there are potential complications associated with surgery, including hematoma, hydrocele and testicular atrophy (1%). Orchiectomy is reserved as the treatment of last resort and should be used only after failure of other medical and surgical approaches, particularly if the patient desires future fertility.
CSCP is a diagnostic and therapeutic challenge. Any final comments concerning treatment and the future?
CSCP can be frustrating for patients and clinicians. Further research in the field will undoubtedly yield more successful treatment options. By employing a consistent algorithm for evaluation and management, clinicians have the opportunity to impart a meaningful benefit on their patients' quality of life.
For more information
Levine LA, et al. Chronic scrotal content pain: A diagnostic and treatment dilemma. Journal of Sexual Medicine. 2018;15:1212.
Sinclair AM, et al. Chronic orchialgia: Consider gabapentin or nortriptyline before considering surgery. International Journal of Urology. 2007;14:622.
Tan WP, et al. What can we do for chronic scrotal content pain? World Journal of Men's Health. 2017;35:146.
Farrell MR, et al. Physical therapy for chronic scrotal content pain with associated pelvic floor pain on digital rectal exam. Canadian Journal of Urology International. 2016;23:8546.