nach oben

Current Urology Reports

Erschienen in:

01.02.2021 | Men's Health (R Carrion, Section Editor)

Chronic Scrotal Content Pain: a Review of the Literature and Management Schemes

verfasst von: Paul J. Oh, Petar Bajic, Scott D. Lundy, Matthew Ziegelmann, Laurence A. Levine

Erschienen in: Current Urology Reports | Ausgabe 2/2021

Einloggen, um Zugang zu erhalten

Abstract

Purpose of Review

Chronic scrotal content pain (CSCP) is a complex condition with multiple etiologies that requires a thorough understanding of its pathophysiology, workup, and treatment options. We performed a comprehensive and contemporary review to augment our current understanding of CSCP.

Recent Findings

We discuss new advances in CSCP-specific pain questionnaires, modern studies of microscopic spermatic cord denervation and its variations, and novel techniques including electric nerve stimulation and cryoablation in addition to randomized control trials with significant negative findings. We also present literature focusing on the prevention of CSCP secondary to surgical iatrogenic causes.

Summary

The constantly evolving literature of CSCP has led to the significant evolution in its diagnosis and treatment, from oral medications to salvage options after microscopic spermatic cord denervation. With each advance, we come closer to developing a more thorough, evidence-based algorithm to guide urologists in treatment of CSCP.

•• Polackwich AS, Arora HC, Li J, Levine L, Tojuola B, Parekattil S, et al. Development of a clinically relevant symptom index to assess patients with chronic orchialgia/chronic scrotal content pain. Transl Androl Urol. 2018;7(Suppl 2):S163–8 Developed an orchialgia symptom index with domains of pain, sexual symptoms, and quality of life. One hundred thirteen men filled the survey and plans are to prospectively validate this survey.PubMedPubMedCentral

Davis BE, Noble MJ, Weigel JW, Foret JD, Mebust WK. Analysis and management of chronic testicular pain. J Urol. 1990;143(5):936–9. https://doi.org/10.1016/S0022-5347(17)40143-1.CrossRefPubMed

Hunter CW, Stovall B, Chen G, Carlson J, Levy R, Hunter CW. Anatomy, pathophysiology and interventional therapies for chronic pelvic pain: a review. Pain Physician. 2018;(1):147–67 Available from: http://www.painphysicianjournal.com/current/pdf?article=NTEwNA%3D%3D&journal=110.

Gaudet AD, Popovich PG, Ramer MS. Wallerian degeneration: gaining perspective on inflammatory events after peripheral nerve injury. J Neuroinflammation. 2011;8(1):110 Available from: http://www.jneuroinflammation.com/content/8/1/110.PubMedPubMedCentral

Calixte N, Brahmbhatt J, Parekattil S. Chronic testicular and groin pain: pathway to relief. Curr Urol Rep. 2017;18(10):1–8.

Parekattil SJ, Gudeloglu A, Brahmbhatt JV, Priola KB, Vieweg J, Allan RW. Trifecta nerve complex: potential anatomical basis for microsurgical denervation of the spermatic cord for chronic orchialgia. J Urol. 2013;190(1):265–70. https://doi.org/10.1016/j.juro.2013.01.045.CrossRefPubMed

Thacker MA, Clark AK, Marchand F, McMahon SB. Pathophysiology of peripheral neuropathic pain: immune cells and molecules. Anesth Analg. 2007;105(3):838–47.PubMed

Dubový P. Wallerian degeneration and peripheral nerve conditions for both axonal regeneration and neuropathic pain induction. Ann Anat. 2011;193(4):267–75.PubMed

Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(SUPPL.3):2–15.

10.

Büntjen L, Hopf JM, Merkel C, Voges J, Knape S, Heinze HJ, et al. Somatosensory misrepresentation associated with chronic pain: Spatiotemporal correlates of sensory perception in a patient following a complex regional pain syndrome spread. Front Neurol. 2017;8(APR):1–6.

11.

Cesmebasi A, Yadav A, Gielecki J, Tubbs RS, Loukas M. Genitofemoral neuralgia: a review. Clin Anat. 2015;28(1):128–35.PubMed

12.

Sakai T, Murata H, Hara T. A case of scrotal pain associated with genitofemoral nerve injury following cystectomy. J Clin Anesth. 2016;32:150–2. https://doi.org/10.1016/j.jclinane.2016.02.022.CrossRefPubMed

13.

Rab M, Ebmer J, Dellon A. Anatomic variability of the ilioinguinal and genitofemoral nerve: implications for the treatment of groin pain.pdf. Plast Reconstr Surg 2001;108:1618–1623.

14.

Patel AP. Anatomy and physiology of chronic scrotal pain. Transl Androl Urol. 2017;6(Suppl 1):S51–6.PubMedPubMedCentral

15.

Oka S, Shiraishi K, Matsuyama H. Microsurgical anatomy of the spermatic cord and spermatic fascia: distribution of Lymphatics, and sensory and autonomic nerves. J Urol. 2016;195(6):1841–7. https://doi.org/10.1016/j.juro.2015.11.041.CrossRefPubMed

16.

•• Tan WP, Tsambarlis PN, Levine LA. Microdenervation of the spermatic cord for post-vasectomy pain syndrome. BJU Int. 2018;121(4):667–73 Evaluated outcomes of patients who underwent microscopic cord denervation for post-vasectomy pain syndrome. Twenty-seven patients were studied with overall success rate 71%.PubMed

17.

Lucas PL, Rose NR. Immunological consequences of vasectomy: I. prospective study through one-year postvasectomy. J Reprod Syst. 1978;1(3):249–55.

18.

Leslie TA, Illing RO, Cranston DW, Guillebaud J. The incidence of chronic scrotal pain after vasectomy: a prospective audit. BJU Int. 2007;100(6):1330–3.PubMed

19.

Manikandan R, Srirangam SJ, Pearson E, Collins GN. Early and late morbidity after vasectomy: a comparison of chronic scrotal pain at 1 and 10 years. BJU Int. 2004;93(4):571–4.PubMed

20.

Johnson AL, Howards SS. Intratubular hydrostatic pressure in testis and epididymis before and after vasectomy. Am J Phys. 1975;228(2):556–64.

21.

McGee S. Referred scrotal pain: case reports and review. J Gen Intern Med. 1993;8:694–701.PubMed

22.

Simons D, Travell J, Simons L. In: Johnson E, Napora L, editors. Travell & Simons’ myofascial pain and dysfunction: upper half of body. 2nd ed. Baltimore: Lippincott Williams & Wilkins; 1999.

23.

Gozon B, Chu J, Schwartz I. Lumbosacral radiculopathic pain presenting as groin and scrotal pain: pain management with twitch-obtaining intramuscular stimulation. A case report and review of literature. Electroencephalogr Clin Neurophysiol. 2001;41(5):315–8.

24.

Farrell MR, Dugan SA, Levine LA. Physical therapy for chronic scrotal content pain with associated pelvic floor pain on digital rectal exam. Can J Urol. 2016;23(6):8546–50.PubMed

25.

Tos P, Crosio A, Pugliese P, Adani R, Toia F, Artiaco S. Painful scar neuropathy: principles of diagnosis and treatment. Plast Aesthetic Res. 2015;2(4):156.

26.

Aljumaily A, Al-Khazraji H, Gordon A, Lau S, Jarvi KA. Characteristics and etiologies of chronic scrotal pain: a common but poorly understood condition. Pain Res Manag. 2017:2–7.

27.

Parekattil SJ, Cohen MS. Robotic surgery in male infertility and chronic orchialgia. Curr Opin Urol. 2010;20(1):75–9.PubMed

28.

•• Khandwala YS, Serrano F, Eisenberg ML. Evaluation of external vibratory stimulation as a treatment for chronic scrotal pain in adult men: a single center open label pilot study. Scand J Pain. 2017;17:403–7. https://doi.org/10.1016/j.sjpain.2017.10.002Proof-of-concept study in which nine men completed at least 2 weeks of external vibratory stimulation for chronic scrotal content pain. Seventy-eight percent of men achieved some improvement in daily scrotal pain levels with also decrease in frequency of pain.CrossRefPubMed

29.

Rottenstreich M, Glick Y, Gofrit ON. Chronic scrotal pain in young adults. BMC Res Notes. 2017;10(1):1–5.

30.

Tan WP, Levine LA. Micro-denervation of the spermatic cord for post-vasectomy pain management. Sex Med Rev. 2018;6(2):328–34. https://doi.org/10.1016/j.sxmr.2017.06.002.CrossRefPubMed

31.

Tan WP, Levine LA. An overview of the management of post-vasectomy pain syndrome. Asian J Androl. 2016;18(3):332–7.PubMedPubMedCentral

32.

Heidenreich A, Olbert P, Engelmann UH. Management of chronic testalgia by microsurgical testicular denervation. Eur Urol. 2002;41(4):392–7.PubMed

33.

Hu JC, Link CL, McNaughton-Collins M, Barry MJ, McKinlay JB. The association of abuse and symptoms suggestive of chronic prostatitis/chronic pelvic pain syndrome: results from the Boston Area Community Health survey. J Gen Intern Med. 2007;22(11):1532–7.PubMedPubMedCentral

34.

Levine L. Chronic orchialgia: evaluation and discussion of treatment options. Ther Adv Urol. 2010;2(5–6):209–14.PubMedPubMedCentral

35.

Benson JS, Abern MR, Larsen S, Levine LA. Does a positive response to spermatic cord block predict response to microdenervation of the spermatic cord for chronic scrotal content pain? J Sex Med. 2013;10(3):876–82.PubMed

36.

Hanna GB, Byrne D, Townell N. Right-sided varicocele as a presentation of right renal tumours. Br J Urol. 1995;75(6):798–9.PubMed

37.

Bonfitto M, Kimura LSM, Godoy JMP, Filho MZ, Spessoto LCF, Junior FNF. Does right-sided varicocele indicate a right-sided kidney tumor? Arch Ital di Urol e Androl. 2019;91(1):53–4.

38.

Street EJ, Justice ED, Kopa Z, Portman MD, Ross JD, Skerlev M, et al. The 2016 European guideline on the management of epididymo-orchitis. Int J STD AIDS. 2017;28(8).

39.

Pischedda A, Fusco F, Curreli A, Grimaldi G, Farina FP. Pelvic floor and sexual male dysfunction. Arch Ital di Urol e Androl. 2013;85(1):1–7.

40.

Myers C, Smith M. Pelvic floor muscle training improves erectile dysfunction and premature ejaculation: a systematic review. Physiother (United Kingdom). 2019;105(2):235–43. https://doi.org/10.1016/j.physio.2019.01.002.CrossRef

41.

Cohen D, Gonzalez J, Goldstein I. The role of pelvic floor muscles in male sexual dysfunction and pelvic pain. Sex Med Rev. 2016;4(1):53–62. https://doi.org/10.1016/j.sxmr.2015.10.001.CrossRefPubMed

42.

Ho KY, Gwee KA, Cheng YK, Yoon KH, Hee HT, Omar AR. Nonsteroidal anti-inflammatory drugs in chronic pain: implications of new data for clinical practice. J Pain Res. 2018;11:1937–48.PubMedPubMedCentral

43.

Najari B, Robinson B, Paget S, Paduch D. Clinical, radiographic, and pathologic description of IgG4-related perivasal fibrosis: a previously undescribed etiology of chronic orchialgia. Urology. 2014;84(4):748–50.PubMed

44.

Agarwal MM, Elsi Sy M. Gabapentenoids in pain management in urological chronic pelvic pain syndrome: gabapentin or pregabalin? Neurourol Urodyn. 2017;36(8):2028–33.PubMed

45.

Sinclair AM, Miller B, Lee LK. Chronic orchialgia: consider gabapentin or nortriptyline before considering surgery. Int J Urol. 2007;14(7):622–5.PubMed

46.

Huecker M, Azadfard M, Leaming J. Opioid addiction: StatPearls Publishing; 2020.

47.

Opioid Overdose Crisis. National Institute on Drug Abuse; 2018.

48.

• Bose J, Hedden S, Lipari R, Park-Lee E. Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. 2018. Contemporary 2017 data on substance use and mental health indicators in the United States. Provides up to date information on opioid prescriptions and abuse.

49.

• Theisen K, Jacobs B, Macleod L, Davies B. The United States opioid epidemic: a review of the surgeon’s contribution to it and health policy initiatives. BJU Int. 2018;122(5):754–9 Provides input on the surgeon’s contribution to the opioid epidemic in the USA.PubMed

50.

•• Welk B, McClure JA, Clarke C, Vogt K, Campbell J. An opioid prescription for men undergoing minor urologic surgery is associated with an increased risk of new persistent opioid use. Eur Urol. 2020;77(1):68–75. https://doi.org/10.1016/j.eururo.2019.08.031Examined persistent opioid use after post-operative opioid prescription for low acuity urologic surgery. Retrospective study with 32,174 patients who filled prescription for opioid pain medications after minor urological surgery (mostly vasectomy). Significantly higher long-term opioid use and overdose with patients who filled opioid prescriptions.CrossRefPubMed

51.

Patil S, Kamtikar S. Treatment of post-operative orchialgia with therapeutic unilateral penile and spermatic cord block. Indian J Anaesth. 2012;56(3):315–6.PubMedPubMedCentral

52.

• Farag A, Basha M, Amin S, Elnaidany N, Elhelbawy N, Mostafa M, et al. Tramadol (opioid) abuse is associated with a dose-and time-dependent poor sperm quality and hyperprolactinaemia in young men. Andrologia. 2018;50(6) Study with 30 participants that determined that tramadol use is associated with poor sperm quality, hyperprolactinamia, and hypergonadotropic hypogonadism.

53.

Ziegelmann MJ, Farrell MR, Levine LA. Evaluation and management of chronic scrotal content pain-a common yet poorly understood condition. Rev Urol. 2019;21(2–3):74–84.PubMedPubMedCentral

54.

Cohen SP, Foster A. Pulsed radiofrequency as a treatment for groin pain and orchialgia. Urology. 2003;61(3):645.PubMed

55.

Basal S, Ergin A, Yildirim I, Goktas S, Atim A, Sizlan A, et al. A novel treatment of chronic orchialgia. J Androl. 2012;33(1):22–6.PubMed

56.

•• Hetta DF, Mahran AM, Kamal EE. Pulsed radiofrequency treatment for chronic post-surgical orchialgia: A double-blind, sham-controlled, randomized trial: three-month results. Pain Physician. 2018;21(2):199–205 Evaluated the analgesic efficacy of pulsed radiofrequency (PRF) applied to the ilioinguinal nerve and the genital branch of the genitofemoral nerve. Seventy percent of participants (35 treated with PRF) with 80% success rate versus 23% in sham.PubMed

57.

Gibson W, Wand BM, O’Connell NE. Transcutaneous electrical nerve stimulation (TENS) for neuropathic pain in adults. Cochrane Database Syst Rev. 2017;2017(9).

58.

•• Tantawy SA, Kamel DM, Abdelbasset WK. Does transcutaneous electrical nerve stimulation reduce pain and improve quality of life in patients with idiopathic chronic orchialgia? A randomized controlled trial. J Pain Res. 2018;11:77–82 Investigated how effective transcutaneous electrical nerve stimulation (TENS) is in pain reduction and quality of life in chronic scrotal pain. Seventy-one patients were randomly assigned; 36 received TENS. TENS associated with significant reduction in pain sustained at 2-month follow-up and also improved quality of life.PubMed

59.

McJunkin TL, Wuollet AL, Lynch PJ. Sacral nerve stimulation as a treatment modality for intractable neuropathic testicular pain. Pain Physician. 2009;12(6):991–5.PubMed

60.

Kiritsy MP, Siefferman JW. Spinal cord stimulation for intractable testicular pain: case report and review of the literature. Neuromodulation. 2016;19(8):889–92.PubMed

61.

Nouri KH, Brish EL. Spinal cord stimulation for testicular pain. Pain Med. 2011;12(9):1435–8.PubMed

62.

Hassanain M, Murphy P. Dorsal root ganglion stimulation for the treatment of bilateral intractable chronic testicular pain. Neuromodulation. 2019;22(1):115–6.PubMed

63.

Strebel RT, Leippold T, Luginbuehl T, Muentener M, Praz V, Hauri D. Chronic scrotal pain syndrome: management among urologists in Switzerland. Eur Urol. 2005;47(6):812–6.PubMed

64.

Chen T, Ball R. Epididymectomy for post-vasectomy pain: histological review. Br J Urol. 1991;68(4):407–13.PubMed

65.

•• Calixte N, Tojuola B, Kartal I, Gudeloglu A, Hirsch M, Etafy M, et al. Targeted robotic assisted microsurgical denervation of the spermatic cord for the treatment of chronic orchialgia or groin pain: a single center, large series review. J Urol. 2018;199(4):1015–22. https://doi.org/10.1016/j.juro.2017.10.030Examined outcomes of ligation of spermatic cord trifecta nerves using a technique of targeted robotic-assisted microsurgical denervation of the spermatic cord. Retrospective study of 772 patients with results showing 83% reduction in pain sustained at 4-year follow-up.CrossRefPubMed

66.

•• Kavoussi P. Validation of targeted microsurgical spermatic cord denervation: comparison of outcomes to traditional complete microsurgical spermatic cord denervation. Asian J Androl. 2019;21(July):1–4 Validated the effectiveness of targeted microsurgical spermatic cord denervation of the trifecta nerve complex. Forty-three patients with trifecta dissection versus 39 underwent complete skeletonization of spermatic cord. No statistically significant difference in resolution of pain, partial improvement of pain, or failure to respond rates. Significant decrease in operating room time with trifecta approach was noted.

67.

Smith-Harrison LI, Smith RP. Vasectomy reversal for post-vasectomy pain syndrome. Transl Androl Urol. 2017;6(I):S10–3.PubMedPubMedCentral

68.

Nangia AK, Myles JL, Thomas AJ. Vasectomy reversal for the post-vasectomy pain syndrome: a clinical and histological evaluation. J Urol. 2000;164(6):1939–42.PubMed

69.

Lee JY, Cho KS, Lee SH, Cho HJ, Cho JM, Oh CY, et al. A comparison of epididymectomy with vasectomy reversal for the surgical treatment of postvasectomy pain syndrome. Int Urol Nephrol. 2014;46(3):531–7.PubMed

70.

Levine LA, Hoeh MP. Evaluation and Management of Chronic Scrotal Content Pain. Curr Urol Rep. 2015;16(6):1–8.

71.

Costabile R, Hahn M, McLeod D. Chronic orchalgia in the pain prone patient: the clinical perspective.pdf. J Urol 1991;146:1571–1574.

72.

•• Calixte N, Kartal IG, Tojuola B, Gudeloglu A, Etafy M, Brahmbhatt JV, et al. Salvage ultrasound-guided targeted cryoablation of the perispermatic cord for persistent chronic scrotal content pain after microsurgical denervation of the spermatic cord. Urology. 2019;130:181–5. https://doi.org/10.1016/j.urology.2019.04.027Examined efficacy of ultrasound-guided targeted cryoablation of the peri-spermatic cord as a salvage treatment for patients who failed spermatic cord denervation. Two hundred seventy-nine cases underwent salvage cryoablation of genitofemoral, ilioinguinal, and inferior hypogastric nerves medial and lateral to spermatic cord at external inguinal ring level. Seventy-five percent reduction in pain with VAS. Fifty-three percent reduction in pain with PIQ-6 at 1 month, increased to 64% by 5-year follow-up.CrossRefPubMed

73.

Group CS. Treatment of painful diabetic neuropathy with topical capsaicin. A multicenter, double-blind, vehicle-controlled study. Arch Intern Med. 1991;151(11):2225–9.

74.

Group CS. Effect of treatment with capsaicin on daily activities of patients with painful diabetic neuropathy. Capsaicin Study Group. Diabetes Care. 1992;15(2):159–65.

75.

Watson C, Tyler K, Bickers D, Millikan L, Smith S, Coleman E. A randomized vehicle-controlled trial of topical capsaicin in the treatment of postherpetic neuralgia. Clin Ther. 1993;15(3):510–26.PubMed

76.

• Gudin J, Fudin J. A narrative pharmacological review of buprenorphine: a unique opioid for the treatment of chronic pain. Pain Ther. 2020;9(1):41–54. https://doi.org/10.1007/s40122-019-00143-6Provides thorough updates on buprenorphine’s mechanism of action including pharmacokinetics and pharmacodynamics as well as trends in its usage.CrossRefPubMedPubMedCentral

77.

Nicol A, Hurley R. Alternatives to opioids in the pharmacologic management of chronic pain syndromes: a narrative review of randomized, controlled, and blinded clinical trials. Anesth Analg. 2017;176(3):139–48.

78.

Blonk MI, Koder BG, Bemt PMLA, va. den Huygen FJPM. Use of oral ketamine in chronic pain management: a review. Eur J Pain. 2010;14(5):466–72. https://doi.org/10.1016/j.ejpain.2009.09.005.CrossRefPubMed

79.

Niesters M, Martini C, Dahan A. Ketamine for chronic pain: risks and benefits. Br J Clin Pharmacol. 2014;77(2):357–67.PubMedPubMedCentral

80.

•• Dockray J, Aljumaily A, Lau S, Jarvi KA. A randomized, double-blind, controlled trial shows that onabotulinum toxin a nerve blocks do not provide improved pain control in men with chronic scrotal pain. J Urol. 2020;203(4):767–72 Double-blind randomized control trial evaluating the use of onabotulinum toxin A to chemically denervate the testis in spermatic cord blocks to treat chronic scrotal content pain. Sixty-four men participated with 32 in the treatment arm (lidocaine and onabotulinum A) versus 32 (lidocaine alone). No difference in outcomes was noted. Significant placebo effect noted in the open trial arm.PubMed

81.

Ronka K, Vironen J, Kokki H, Liukkonen T, Paajanen H. Role of orchiectomy in severe testicular pain after inguinal hernia surgery: audit of the Finnish Patient Insurance Centre. Hernia. 2015;19:53–9.PubMed

82.

Alfieri S, Amid PK, Campanelli G, Izard G, Kehlet H, Wijsmuller AR, et al. International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia. 2011;15(3):239–49.PubMed

83.

Ducic I, Dellon AL. Testicular pain after inguinal hernia repair: an approach to resection of the genital branch of genitofemoral nerve. J Am Coll Surg. 2004;198(2):181–4.PubMed

84.

Srivastava A, Kapoor R, Srivastava A, Ansari M, Singh M, Kapoor R. Orchialgia after laproscopic renal surgery: a common problem with questionable etiology. Are There Any Predictors? World J Urol. 2013;31(5).

85.

Sureka S, Srivastava A, Agarwal S, Srivastava A, Sachin A, Singh S, et al. Prevention of orchialgia after left-sided laparoscopic donor nephrectomy—a prospective study. J Endourol. 2015;29(6):696–9.PubMedPubMedCentral

86.

Shapiro EI, Silber SJ. Open-ended vasectomy, sperm granuloma, and postvasectomy orchialgia. Fertil Steril. 1979;32(5):546–50. https://doi.org/10.1016/S0015-0282(16)44357-8.CrossRefPubMed

87.

Moss W. A comparison of open-end versus closed-end vasectomies: a report on 6220 cases. Contraception. 1992;46(6):521–5.PubMed

Titel: Chronic Scrotal Content Pain: a Review of the Literature and Management Schemes
verfasst von: Paul J. Oh
Petar Bajic
Scott D. Lundy
Matthew Ziegelmann
Laurence A. Levine
Publikationsdatum: 01.02.2021
Verlag: Springer US
Erschienen in: Current Urology Reports / Ausgabe 2/2021
Print ISSN: 1527-2737
Elektronische ISSN: 1534-6285
DOI: https://doi.org/10.1007/s11934-020-01026-6

Neu im Fachgebiet Urologie

„Überwältigende“ Evidenz für Tripeltherapie beim metastasierten Prostata-Ca.

22.05.2024 Prostatakarzinom Nachrichten

Patienten mit metastasiertem hormonsensitivem Prostatakarzinom sollten nicht mehr mit einer alleinigen Androgendeprivationstherapie (ADT) behandelt werden, mahnt ein US-Team nach Sichtung der aktuellen Datenlage. Mit einer Tripeltherapie haben die Betroffenen offenbar die besten Überlebenschancen.

Update Urologie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Die Highlights vom Kongress des American College of Cardiology 2024

Springer Medizin

Chronic Scrotal Content Pain: a Review of the Literature and Management Schemes