Pediatric chronic orchalgia

Resolution of post-traumatic chronic testicular pain in a pediatric patient after microsurgical denervation of the spermatic cord: a case report

PURPOSE

Chronic scrotal content pain, chronic orchialgia, or testicular pain can present after trauma, vasectomy, and hernia repair, among other triggers. Microsurgical denervation of the spermatic cord is an option for definitive pain control. While this practice is established in adult urology, access to diagnostic intervention and definitive denervation surgery is limited in the pediatric population.

CLINICAL FEATURES

We report a case of definitive resolution of testicular pain with microsurgical denervation of the spermatic cord in a pediatric patient with post-traumatic chronic orchialgia that significantly reduced his daily activities and worsened his anxiety prior to this treatment. The patient underwent attempts at conservative medication-based management, followed by diagnostic spermatic cord nerve block before definitive denervation surgery.

CONCLUSIONS

The incidence of chronic pain in pediatrics is substantial and is estimated to be around 20%. Orchialgia remains difficult and problematic to treat. Mental health diagnoses such as anxiety and depression are also significantly associated with chronic pain. Following consideration and implementation of steps for all these concerns, a diagnostic block and microsurgical denervation led to successful resolution of chronic testicular pain in a pediatric patient.

High Inguinal Microsurgical Denervation of the Spermatic Cord for Chronic Scrotal Content Pain: A Novel Approach for Adult and Pediatric Patients

OBJECTIVE

To improve the technique and results of microsurgical denervation of the spermatic cord (MDSC) for men with chronic scrotal content pain, we describe a novel approach at the level of the internal inguinal ring for the complete transection of the nerves running both inside and outside the spermatic cord for adults and children.

METHODS

A retrospective review of 52 patients (64 testicular units) who underwent high inguinal MDSC was performed. Visual analogue scale (VAS, 1-10) scores were compared with before and every 3 months after the surgery. Depressive symptoms were assessed by the Beck Depression Inventory. Hormonal evaluations were performed before and 6 months after the surgery.

RESULTS

The average patient age was 52.4 years (12-78); including 6 pediatric cases. The mean operative time was 67 minutes per testicular unit, and there were no major complications. The mean pre- and post-MDSC VAS scores were 8.3 and 2.5, respectively (P < .0001). Forty-six (88%) cases showed positive responses after MDSC, and multivariate analysis showed that pain outside the scrotum and depressive symptoms were predictors of MDSC failure (P < .05, odds ratio: 15.27 and 12.56, respectively).

CONCLUSION

For both adult and pediatric patients, high inguinal MDSC is an effective and safe management option, including testicular function, for the chronic scrotal content pain that is refractory to medical management. We find that the high inguinal approach is easier in our experience than the subinguinal approach because of fewer divisions of veins, a larger diameter of the spermatic artery.

Chronic orchalgia after surgical exploration for acute scrotal pain in children

OBJECTIVES

The aim was to review the pediatric cohort undergoing surgical exploration for acute scrotal pain at our institution and assess the entity of chronic orchalgia post exploration in this cohort.

MATERIALS AND METHODS

A retrospective review of all pediatric patients who underwent surgery for acute scrotal pain at a single institution between 1 January 2001 and 1 January 2012 was conducted.

RESULTS

A total of 1084 patients underwent scrotal exploration for acute scrotal pain where the underlying cause could not be clinically ascertained. Causes found at exploratory surgery are shown in the table. Forty-four children (4.1%) re-presented with another episode of acute scrotal pain and underwent re-exploration. A hundred of the 772 children with testicular appendage torsion at initial exploration had unilateral exploration only. Seven (7%) of these re-presented with contralateral appendage torsion. The complication rate of initial scrotal exploration was 5.6% and that of re-exploration was 6.8%. All complications were managed conservatively except for a painful reactive hydrocele that underwent the Jaboulay procedure. Fifteen (1.4%) children in this cohort developed chronic orchalgia. Thirteen (87%) of these had definite pathology found at initial exploration. One of 61 (2%) with postoperative complications (a reactive hydrocele) developed chronic orchalgia. Pediatric chronic pain specialists were consulted for all patients. In 10 of the 15 (67%), significant comorbidities included constipation, anxiety, somatization, hydrocele, dysfunctional voiding, and multiple joint pain. The Jaboulay procedure for reactive hydrocele and re-exploration to pex the testes due to suspected intermittent testicular torsion resolved chronic orchalgia in one patient each.

DISCUSSION

Pediatric chronic orchalgia post exploration is uncommon. It has a multifactorial etiology. Comorbidities are common. It is possible that some unexplored patients labeled as chronic orchalgia in the literature may have underlying correctable pathology. Surgically correctable pathology such as intermittent testicular torsion, metachronous testicular appendage torsion, and symptomatic hydrocele or varicocele should be excluded in children with chronic orchalgia. Chronic pain specialists should be consulted and associated comorbidities managed. Prior surgical exploration and testicular fixation in children with chronic orchalgia helped reassure patients and families that there was no underlying surgical cause for the pain and facilitated compliance with chronic pain management.

CONCLUSIONS

Pediatric chronic orchalgia has a multifactorial etiology and is uncommon after scrotal exploration surgery. Comorbidities are common and must be managed. Surgical exploration helps reassure patients that there is no correctable cause for the pain and facilitates engagement with chronic pain management.

Pediatric chronic orchialgia: patient population and patterns of care

OBJECTIVE

A major hurdle in management of any chronic pain syndrome is understanding the population in which it occurs. We describe our pediatric population of patients with peripubertal and postpubertal chronic orchialgia.

PATIENTS AND METHODS

Pediatric patients ≥ 10 years of age seen between 2002 and 2012 were identified by ICD code 608.9, Male Genital Disorder NOS. Patients were included if they had orchialgia without identifiable cause lasting >3 months. Patient history, diagnostic evaluations, treatments, and outcomes were assessed.

RESULTS

Seventy-nine pediatric patients were identified. The mean age was 13.3 years (range 10-18); mean duration of orchialgia was 16.3 months (range 3-85). Thirty-three of 79 (42%) had concomitant medical conditions and/or psychiatric-behavioral issues. The mean follow-up was 7.1 months (range 0-70.4) with 41/79 (52%) having more than one office visit follow-up. Eleven patients were referred to a pediatric pain clinic; 10 out of 11 (91%) were evaluated there. Overall, 16 out of 41 (39%) had resolution of pain: nine out of 41 (22%) responding to conservative management vs seven of 10 (70%) responding to pain clinic management (3 to anti-neuropathic medications, 4 to nerve block).

CONCLUSION

Many pediatric patients with chronic orchialgia have co-morbidities amenable to multidisciplinary collaborative coordination of care. Referral to pediatric pain clinic can be of significant benefit.

Ultrasound-guided pulsed radiofrequency ablation of the genital branch of the genitofemoral nerve for treatment of intractable orchalgia

Chronic orchalgia is a frustrating clinical problem for both the patient and the physician. We present a 17-year-old boy with a bilateral idiopathic chronic intractable orchalgia with failed conservative treatment. For 2 years, he suffered from severe attacks of scrotal pain that affected his daily activities and caused frequent absence from school. Ultrasound-guided pulsed radiofrequency ablation (PRF) of the genital branches of the genitofemoral nerve performed after local anesthetic nerve block confirmed the diagnosis and yielded 6 weeks of symptom relief. Seven-month follow-up revealed complete satisfactory analgesia. The use of PRF is an effective and non-invasive approach to treat intractable chronic orchalgia.