Chronic orchialgia can be among the most frustrating conditions urologists treat. Not only is there little evidence to guide treatment, many practitioners fail to apply what guidelines have been created.
“In our referral practices, we see patients being handled quite poorly, ignoring even the small amount of evidence we have,” said Daniel A. Shoskes, MD, professor of Surgery at Cleveland Lerner College of Medicine of Case Western Reserve University and Director of the Novick Center for Clinical and Translational Research at the Cleveland Clinic Glickman Urological and Kidney Institute. “One of the most common reasons I will see a patient with persistent testicular pain is that they were diagnosed with epididymitis and treated with an inappropriate antibiotic that does not penetrate the area properly and is not part of guidelines.”
Dr. Shoskes and three other experts will review a series of chronic orchialgia case studies during Tuesday’s Plenary I program. The 30-minute discussion will begin at 10:55 a.m. in Hall A in the San Diego Convention Center.
While chronic orchialgia may appear to be an insoluble puzzle, the condition can be managed in an algorithmic fashion, Dr. Shoskes said. The general goal is to either help the patient directly or quickly determine that he should be referred to a pain medicine specialist.
Chronic orchialgia is simply the presence of chronic testicular pain with no obvious pathology. It can develop spontaneously or following trauma, inflammation or surgery such as vasectomy or hernia repair. Pain may also be referred to the scrotum from sources such as a kidney stone or a spinal condition that impinges on or inflames the genitofemoral or ilioinguinal nerves. The first step is to look for and treat obvious causes such as infection.
Once the obvious causes of chronic pain have been eliminated, there are two diagnostic steps that can help guide treatment or referral. The first step is a palpitation of the pelvic floor muscles. If there are pelvic floor spasms and trigger points, physical therapy can play an important role in dealing with the chronic pain.
The next step is to attempt a spermatic cord block using a local anesthetic.
“If that injection does not help the pain in any way, the chance that the urologist has anything useful to offer is quite small,” Dr. Shoskes said. “At that point, the patient should most likely be referred to a pain management specialist.”
If the temporary spermatic cord block eliminates pain for even a short period of time, it may be appropriate to move to a spermatic cord denervation.
The evidence favoring this procedure is not robust, Dr. Shoskes noted, but several groups have published reports on successful outcomes. After all other medical therapies have failed, more than 70 percent of patients who have had chronic pain for longer than six months and experienced complete temporary relief from a cord block have long-term pain relief.
Tuesday’s expert panel will also review cases that highlight some of the less common and more difficult to discern scenarios, including post-vasectomy pain and pain associated with an overly retractile testicle.
Acute pain from vasectomy can usually be handled routinely, Dr. Shoskes said, but some men experience constant, unremitting pain six months or longer after a vasectomy. For some of these men, spermatic cord denervation may help. Some patients may also benefit from vasectomy reversal.
“We are going to learn about a wide variety of new, fascinating and innovative technologies at the annual meeting,” Dr. Shoskes said. “But at the end of the day, what is waiting for urologists back in the clinic is men with testicular pain. This session can provide strategies to help your patients more effectively and more quickly.
Plenary I Preview
Presenter: Daniel A. Shoskes, MD
10:55 – 11:25 a.m. Tuesday
Hall A, San Diego Convention Center