Diagnosis of Chronic Testicular Pain
The testicle and spermatic cord are common places to suffer chronic and sometimes debilitating pain.
Typical Causes for Testicular/Spermatic Cord Pain
Some of the causes of chronic testicular and spermatic cord pain are:
- Infection, and
- Neurologic disease.
The pain itself can range from just annoying to completely debilitating. After seeing many patients with chronic testicular and cord pain, we have developed a protocol for treatment of these issues.
Typical Causes for Scrotal/Testicular Pain
In chronic scrotal and testicular pain, typical causes are:
- A history of vasectomy,
- A history of epididymitis or orchitis, or
- Previous surgery on the testicle.
In deciding how best to treat this pain, we need to differentiate between local and central pain. As pain exists in any body part for a long time, the brain begins to think of all stimulation and feeling from that area as being painful. This can result from old trauma, infection, or neurologic problems, such as diabetic neuropathy. Sometimes, as in the case of an infection, even if the infection is completely gone, the pain may persist.
Similarly, even if the painful part is removed, the pain may continue. The classic example of this is the diabetic with a foot that needs to be amputated but even after the amputation the patient still has foot pain. This phantom pain is because the nerves coming from the foot going to the brain have become jumbled such that the patient perceives constant pain in a foot that is no longer there.
Most commonly, to determine if the pain is local or central, we use an injection of a local anesthetic and steroid into the spermatic cord in the area of the groin where the patient feels pain. If this temporarily relieves the pain, this indicates that the origin of the pain is in the spermatic cord rather than the brain.
A patient who has testicular pain coming from the spermatic cord may be a candidate for a microscopic denervation of the cord, also knows as neurolysis or microscopic neurolysis of the spermatic cord.
Microsurgical Denervation of the Spermatic Cord
Microscopic denervation of the spermatic cord is done in the operating room with a small incision in the groin, such as where a hernia repair is done. If a hernia repair was already done, we go through the previous scar.
The spermatic cord contains arteries, nerves, the vas deferens and lymphatic vessels. During surgery, these are isolated and we slowly dissect out all of its components in order to preserve the testicular artery and several lymphatic channels. We do with the use of a microsurgical Doppler probe. If the patient is interested in fertility, we also keep the vas deferens intact. If not, we divide the vas deferens and its associated structures.
All of the other structures are divided and then the “skeletonized” cord (the artery and lymphatics) is put back in the normal anatomic position. The incision is then closed with absorbable sutures so there is nothing to remove. Typically, the entire procedure takes one to two hours. The patient may return home or to a hotel that night.
In properly selected patients, we have had excellent results, with over 90 percent of patients achieving between 70–100 percent of pain resolution.
Most insurers will cover this procedure but it is always a good idea for patients to check with their individual insurers before scheduling surgery. If insurance does not cover the procedure, we have developed package pricing.
Medical Management for Chronic Central Testicular and Scrotal Pain
For those patients who do not respond to local therapies, including local injection or microscopic denervation, medical management of their pain will be required. Chronic pain management is a complex problem best left to doctors who specialize in treating pain. We do not believe it is it appropriate for surgeons to medically manage a problem as complicated as chronic pain and do not believe in long-term administration of narcotic medication for pain.
Our treatment policy is as follows:
- We do not prescribe any narcotic pain medications, except in the immediate postoperative period.
- All patients being evaluated for pain must have a backup plan that includes a physician or provider in their local area who is willing to provide long-term pain management in the event this is required. It is the patient's responsibility to arrange this with the physician or clinic of their choice.
- Under no conditions will we manage preoperative pain nor will we provide prescriptions for controlled substances after the immediate postoperative period (two weeks). This is done for the safety of the patient. For clarification of these issues, please do not hesitate to discuss this issue with your surgeon.
William O. Brant, MD FACS FECSM, is a board-certified urologist, specializing in sexual dysfunction, disorders of the penis, Men's Health, Peyronie's disease, male urinary incontinence, scrotal and testicular problems, and prosthetic surgery. He attended Dartmouth College (undergraduate) and the University of Washington, Seattle (graduate) and then... Read More
Dr. Hotaling has significant training in both the clinical aspects of male fertility and genetic epidemiology and he is currently the only fellowship trained male infertility/andrology expert in Utah. He completed a 6 year residency in urology at the University of Washington, elected to pursue a year of sub-specialty training in male infertility ... Read More
Richard is a board certified Physician Assistant. His clinical emphases include men’s health and general urology as well as clinic procedures for hypogonadism, erectile dysfunction, incontinence and Peyronie’s Disease. He works closely with the physicians of the Men’s Health Clinic, including pre-operative and postoperative care. He is a member of ... Read More
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