Alosh Madala, MD
Dmitriy Nikolavsky, MD
BASICS
DESCRIPTION
• Orchalgia is scrotal or testicular pain
– Acute or chronic
– Intermittent or constant
– Unilateral, bilateral, or alternating
• Characteristics:
– Localized to scrotum
– May radiate to groin, perineum, back, or legs
– Chronic orchalgia
Lasting >3 mo
Constant or intermittent pain.
No specific cause is identified in most cases.
– Synonym(s) for chronic testicular pain: Orchalgia; idiopathic testicular pain; orchiodynia; chronic scrotal pain syndrome
EPIDEMIOLOGY
Incidence
• Majority in mid to late 30s
• Increased in men with psychological issues
Prevalence
• Chronic testicular pain
– Idiopathic 25–50%
– Postvasectomy chronic orchalgia
∼15%
RISK FACTORS
• Organic risk factors
– Previous trauma or surgery
Post-vasectomy pain syndrome in 5–43% of men who have undergone this procedure (1)
Posthernia repair
– Scrotal masses
Testicular tumors
Varicocele
Hydrocele
Epididymal cysts or spermatoceles
– Infections
Chronic epididymitis
– Neuropathic conditions
Diabetic neuropathy
Withdrawal from imipramine
• Psychological risk factors
– Life stressors
– Depression
– Secondary gain with malingering
Genetics
No studies exist at this time
PATHOPHYSIOLOGY
• Poorly understood
• Idiopathic in most cases
• Testis innervation
– Sympathetic nerve supply from T10–T12 segments
– Accompany the internal spermatic vessels
– Penetrate the tunica albuginea
– Distributed between the seminiferous tubules
– Stimulates smooth muscles of the tunica albuginea
– Testis shares innervations with the epididymis
• Epididymis and vas deferens innervation
– Sympathetic fibers from T10–L1.
– Supply smooth muscles of vas deferens and epididymis.
ASSOCIATED CONDITIONS
• Often idiopathic (∼25%)
• Can be associated with:
– Previous surgery (vasectomy, hernia repair)
– Trauma
– Intermittent torsion
– Hydrocele, varicocele, spermatocele
– Tumor
– Infection
– Herniated intervertebral disc
– Vasculitis (polyarteritis nodosa)
GENERAL PREVENTION
• USPSTF: Against routine screening for testicular cancer in asymptomatic adolescent and adults including routine testicular self-exams.
• American Cancer Society suggests that men with family history do monthly self-exams.
• American Urological Association (AUA): Monthly self-exams for all young men.
ALERT
Acute onset of testicular pain in a child is most likely torsion, and emergent evaluation is indicated, early surgical intervention; do not delay surgery for imaging.
DIAGNOSIS
HISTORY
• Onset, location, duration, quality, aggravating (exercise, sexual intercourse, or ejaculation) and relieving factors.
• Visual analogue scale (VAS) of 0–10 helps quantify degree of pain
• Consult with multiple physicians including urologists
• Multiple treatments (antibiotics, anti-inflammatory drugs)
– Little or no relief
• Previous surgery
– Scrotal/inguinal
– Vasectomy
– Retroperitoneal/pelvic
• Social/psychological history
– Current life stressors
– Social support
– Sexual function
– Mood and anxiety
– Sexual abuse, relationship stress
• Back injuries or spinal trauma
PHYSICAL EXAM
• Often does not reveal abnormality
• Evaluate genitalia for reversible causes
– Testicular torsion
– Scrotal mass
– Hernia
– Infection
– Varicocele
– Spermatocele
• Sperm granuloma following vasectomy
• Digital rectal exam
– Evaluate prostate and rectum.
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urine analysis and culture
– Before and after prostatic massage
• Semen analysis (for chronic epididymitis)
• Consider STD/STI screening
Imaging
• Scrotal US exam with color flow doppler
– Evaluate scrotal contents
– Rule out testicular torsion and tumor
Diagnostic Procedures/Surgery
Cystoscopy and urodynamics are of limited value
Pathologic Findings
Based on etiology
DIFFERENTIAL DIAGNOSIS (2)
• Chronic pelvic pain syndrome (CPPS)
• Cremasteric spasm
• Hydrocele, spermatocele
• Idiopathic orchalgia
• Infection
– Epididymitis and epididymo-orchitis
– Urethritis
– Prostatitis
– Viral orchitis
– Testicular abscess
• Inguinal hernia (incarcerated, other)
• Nerve entrapment (ilioinguinal or genitofemoral)
• Medical causes: Diabetic neuropathy, polyarteritis nodosa
• Paratesticular tumor
• Postoperative (vasectomy, inguinal herniorrhaphy)
• Psychogenic
• Referred pain (nerve root irritation)
– Disk herniation, back injury, other
• Testicular torsion
• Testicular/scrotal trauma
• Testicular tumor
• Testicular vasocongestion from sexual arousal without ejaculation
• Torsion of testicular/epididymal appendices
• Varicocele
TREATMENT
GENERAL MEASURES
• For acute testicular pain: See Section I “Acute Scrotum”
• For chronic testicular pain
– Scrotal support
– Restrict physical activity
– Sitz baths
MEDICATION
First Line
• NSAIDs
– Variable and usually temporary relief
– Regimens described include ibuprofen 400–600 mg PO q6h for 1 mo
• Antibiotics
– Usually empiric unless specific agent such as STD/STI (chlamydia, etc.) identified
– Often prescribed, rarely beneficial
– Common regimens
Doxycycline 100 mg PO BID or ciprofloxin 250–500 mg PO BID for 2–3 wk
Second-Line (5,6)
• Antidepressants and anticonvulsants
– Demonstrated benefit in chronic idiopathic orchalgia
– Poor response to postvasectomy pain
• Tricyclic antidepressants
– Amitriptyline 10–25 mg qhs
– Nortriptyline 10–150 mg daily
• Anticonvulsants
– Gabapentin 300 mg titrated up to 3,600 mg/d daily
• α-Adrenergic antagonists
– Tamsulosin; no proven benefit
SURGERY/OTHER PROCEDURES
• Acute testicular pain in a child: See Section I “Torsion, Testis or Testicular/Epididymal Appendages”.
• The following are used for the management of chronic pain in an adult.
• Minimally invasive treatment options (7,8)
– Enucleation of cystic lesions
– Local anesthetic infiltration
Spermatic cord
Pelvic plexus under TRUS guidance
• Denervation of spermatic cord (3,9)
– Division of ilioinguinal nerve and its branches
– Microscopic or laparoscopic or robotic
– Best outcome is initial response to spermatic cord block with local anesthetic
• Orchiectomy
– Last resort: Many will continue to have pain
– Inguinal approach superior to scrotal
– >75% patients have relief after surgical removal of varicocele, hydrocele, spermatocele, or intermittent torsion.
• Epididymectomy
– Poor results except in the setting of postvasectomy pain syndrome
• Vasovasostomy in the setting of postvasectomy pain
ADDITIONAL TREATMENT
• Physical therapy
– May be helpful in patients with spinal disk and back problems with nerve root irritation
Radiation Therapy
N/A
Additional Therapies (10,11)
• Pulsed radiofrequency denervation of the spermatic cord (4)
– Not well studied
• Sacral nerve stimulation
– 80% decrease in pain
Complementary & Alternative Therapies
• Mental health consult
– Psychological evaluation
– Psychotherapy
– Should be strongly considered before surgical intervention
• Pelvic muscle exercises
ONGOING CARE
PROGNOSIS
Depends on etiology
COMPLICATIONS
• Surgery
– Epididymectomy may result in loss of testicle or infertility
FOLLOW-UP
Patient Monitoring
Periodic follow-up with urology or other providers depending on etiology (if known)
Patient Resources
Urology Care Foundation: Epididymitis and Orchitis. http://www.urologyhealth.org/urology/index.cfm?article=114&display=1
REFERENCES
1. McConaghy P, Reid M, Loughlin V, et al. Pain after vasectomy. Anaesthesia. 1998;53(1):83–86.
2. Granitsiotis P, Kirk D. Chronic testicular pain: An overview. Eur Urol. 2004;45(4):430–436.
3. Levine LA, Matkov TG, Lubenow TR. Microsurgical denervation of the spermatic cord: A surgical alternative in the treatment of chronic orchialgia. J Urol. 1996;155(3):1005–1007.
4. Cohen SP, Foster A. Pulsed radiofrequency as a treatment for groin pain and orchialgia. Urology. 2003;61(3):645.
5. Sinclair AM, Miller B, Lee LK. Chronic orchialgia: Consider gabapentin or nortriptyline before considering surgery. Int J Urol. 2007;14(7):622–625.
6. Sasaki K, Smith CP, Chuang YC, et al. Oral gabapentin (neurontin) treatment of refractory genitourinary tract pain. Tech Urol. 2001;7(1):47–49.
7. Levine L. Chronic orchialgia: Evaluation and discussion of treatment options. Ther Adv Urol. 2010;2(5-06):209–214.
8. Kumar P, Mehta V, Nargund VH, et al. Clinical management of chronic testicular pain. Urol Int. 2010;84(2):125–131.
9. Strom KH, Levine LA. Microsurgical denervation of the spermatic cord for chronic orchialgia: Long-term results from a single center. J Urol. 2008;180(3):949–953.
10. Basal S, Ergin A, Yildirim I, et al. A novel treatment of chronic orchialgia. J Androl. 2012;33(1):22–26.
11. McJunkin TL, Wuollet AL, Lynch PJ. Sacral nerve stimulation as a treatment modality for intractable neuropathic testicular pain. Pain Physician. 2009;12(6):991–995.
ADDITIONAL READING
Strebel RT, Schmidt C, Beatrice J, et al. Chronic scrotal pain syndrome (CSPS): The widespread use of antibiotics is not justified. Andrology. 2013;1(1):155–159.
See Also (Topic, Algorithm, Media)
• Acute Scrotum
• Chronic Pelvic Pain Syndrome (CPPS)
• Epididymitis
• Paratesticular Tumors
• Prostatitis, Chronic Nonbacterial, Inflammatory & Noninflammatory (NIH CP/CPPS III A and B)
• Scrotal Pain Syndrome (Chronic Scrotal Pain Syndrome [CSPS])
• Scrotum and Testicle, Mass
• Sperm Granuloma
• Spermatocele
• Testis, Pain (Orchalgia) Image 
• Testis, Tumor and Mass, Adult, General Considerations
• Torsion, Testis or Testicular/Epididymal Appendages
• Varicocele, Adult
• Vasectomy and Postvasectomy Pain Syndrome
CODES
ICD9
• 307.89 Other pain disorders related to psychological factors
• 608.89 Other specified disorders of male genital organs
• 959.14 Other injury of external genitals
ICD10
• F45.41 Pain disorder exclusively related to psychological factors
• N50.8 Other specified disorders of male genital organs
• S39.94XA Unspecified injury of external genitals, initial encounter
CLINICAL/SURGICAL PEARLS
• The presence or absence of pain or tenderness alone cannot reliably rule in or out benign vs. malignant processes in the scrotum or testis.
• Physical exam is often normal with testicular pain.
• Ultrasound is the most valuable study.
• Surgical options should only be considered after medical and conservative management fails for chronic testicular pain.