Scrotal pain: A challenging diagnostic and therapeutic entity

Although we lack founded epidemiological data, scrotal pain is a common complaint in a urological practice. The diagnosis can be challenging in both acute and chronic forms and therefore needed to be carefully evaluated with full patient history and physical examination, which sometimes may be prevented because of the pain and oedema.

Nevertheless, there are no available clinical guidelines concerning this challenging problem. Probably because majority of guidelines are disease and not symptom oriented. Therefore, in this article and during the presentation, the important issues concerning the diagnosis and the treatment approach will be symptom-oriented. In this respect, when dealing with scrotal pain we need to distinguish between two forms of scrotal pain, the acute and the chronic one.

Acute scrotal/testicular pain: To operate or not to operate is the question
The “acute scrotum” may be viewed as the urologist’s equivalent to the general surgeon’s “acute abdomen.” Both conditions are guided by similar management principles: the patient history and physical examination are keys to the diagnosis and often guide decision-making regarding whether or not surgical intervention is appropriate. Imaging studies should complement, but not replace, sound clinical judgment. When making a decision for conservative care, the provider must balance the potential morbidity of surgical exploration against the potential cost of missing a surgical diagnosis. A small but real, negative exploration rate is acceptable to minimize the risk of missing a critical surgical diagnosis.

Studies show that the commonest cause of acute scrotum is epididymo-orchitis, followed by torsion of appendages. The most common cause in boys of preschool age are spermatic cord torsion. The low temperatures during winter may account for the increased incidence of the torsion of both the spermatic cord torsion and the appendages. Other important causes to remember are incarcerated inguinal hernia, trauma, gangrenous infections or complications of testicular cancer (infarction or hemorrhage). Rare are inflammations like Henoch- Schonlein purpura (HSP) and fat necrosis of scrotal wall. Acute scrotal pain could also be a referred pain due to, for example, ureter stone.

There is no single feature in the history, examination or investigation (mainly Doppler ultrasound and urine studies) that is pathognomonic for the diagnosis, the triad together is pivotal for the evaluation. Doppler ultrasound can assess anatomy and blood flow as well as localization of fluid collection or hernia. In the table below some of the distinguishing conditions of acute scrotal pain in adults are given.

According to the finding on the history, examination and investigation, treatment steps should follow.
The presentation will focus on the treatment consideration according to the diagnostic steps. The urologist should remember that a full range of scrotal pathology must be considered in acute scrotum cases. Several conditions that result in acute scrotum (e.g. trauma and testicle torsion) require surgical exploration, making this a very time sensitive condition. When testicular torsion is highly suspected, surgical exploration should follow. When epididymo- orchitis is obvious, exclude sexual transmitted infection and appropriate antibiotics should be prescribed. When the clinical diagnosis is in doubt, urine analysis and Doppler ultrasound should be performed and management should be according to the findings.

Chronic scrotal pain syndrome (CSPS)/ orchidalgia: A frustrating issue for the clinician and the patient
The term “hidden epidemic” has been used when discussing chronic scrotal pain. This debilitating condition is associated with anxiety and frustration and characterized by intermittent or constant uni- or bilateral scrotal pain, occurring for at least 3 months that has a significant negative impact on daily life. This condition certainly represents symptom complex with little in the way of evidence to support specific medical and surgical interventions. These patients are challenging to both the urologist and the GP, and managing patient expectations when a cure may not be feasible can be difficult.

According to the EAU chronic pelvic pain guidelines, we don’t have any reliable estimation on incidence and prevalence of chronic scrotal/testicular pain. In The Netherlands, the incidence is estimated at 350–400 cases per 100,000 men per year. In the USA, it affects up to 100,000 men per year due to varying etiologies. In the United Kingdom, the incidence has been estimated around 1%.

In about 25-50% of cases of chronic scrotal pain, no causes are found. The urologists should take into consideration causes of chronic scrotal pain like, diabetic neuropathy, spermatocele/hydrocele, chronic epididymitis, herniated lumbar disc, inguinal hernia, painful bladder syndrome, prostatitis and other referred pain causes from abdomen/pelvis. Often CSPS is not associated with any specific pathology and the pain is perceived in testes, epididymis or vas deference. Two special form can be distinguished. The post-vasectomy pain syndrome, with incidence of 2-20% and can appear in all vasectomy techniques used. Lower risk is described in the no-scalpel vasectomy. The other form is post-inguinal hernia repair. Incidence is higher in the laparoscopic in comparison with open hernia repair.

It should be noticed that as the scrotum is innervated by the ilioinguinal, genitofemoral and pudendal nerves, any pathology at the origin and course of these nerves may results in perception of scrotal pain. The nerves in the spermatic cord play an important role in scrotal pain.

The clinician must be cautious about assuming that chronic scrotal pain is constitutive in the chronic pelvic pain syndrome, and must be diligent in ruling out specific etiologies for scrotal pain prior to managing it as a non-specific chronic pain syndrome.

Cause Pain location Cremaster reflex Other findings
Testicular Torsion Testis Negative Profound swelling & high riding testis
Epididymitis Epididymis Positive Epididymis induration, positive urine test
Fournier’s gangrene Diffuse Positive Edema of the skin, crepitus, fever, rigors
Appendicular Torsion Upper pole of testis Positive Tenderness of the anterior side of testis

CSPS may be associated with LUTS or sexual dysfunction but also with negative cognitive, behavioral, sexual or emotional consequences. Past emotional or physical abuse and adverse life-events are common in some of the men with CSPS and the patient should be asked about it as well.

After profound history taking about pain, anxiety, depression, overall function, LUTS, sexual function and physical examination should be performed which serve to confirm or exclude specific diseases associated with scrotal pain. Pelvic floor examination should be included as for men with CSCP and a positive pelvic floor exam with DRE, a trial of pelvic floor physical therapy can be an effective and
non-operative treatment modality. Scrotal ultrasound usually does not help in the diagnosis of CSPS, it is often used to exclude intra-scrotal or inguinal pathology.

The desired goal of the treatment is to allow the patient to return to routine activity without use of significant analgesics. As with any chronic pain condition, an honest, frank discussion with the patient about reasonable expectations is critical. There are many possible treatment modalities available, for which no good clinical practice guidelines exist. These include medication (antibiotics, NSAIDs, Alpha-adrenergic antagonists, tricyclic antidepressants, gabapentin, carbamazepine), minimal invasive (transcutaneous nerve stimulation, spermatic cord blockade, pelvic plexus blockade under TRUS) and surgical interventions (microsurgical denervation of spermatic cord or testicles, orchiectomy). Orchiectomy is the last resort in treatment of CSPS and should only be done if other therapies have failed. For post- vasectomy pain, vaso-vasostomy can be performed. A multidisciplinary approach is often required so that the patient can benefit from different treatment modalities available at present.

In conclusion, due to multiple etiologies and variable treatment outcomes, scrotal pain in acute or chronic form has been and will continue to be a challenging complaint to manage. Although treatment options are improving, further and better studies are warranted for better understanding of the cause and the
long-term effects. Developing of guidelines or standard operating procedures based on presented symptoms could help the urologists in management of the patients.

Saturday 25 March
08.45-9.00: Plenary Session 2, Hot topics in andrology

Dr. Yacov Reisman Amstelland Hospital Amstelveen (NL)