Salvage Ultrasound-guided Targeted Cryoablation of The Perispermatic Cord For Persistent Chronic Scrotal Content Pain After Microsurgical Denervation Of The Spermatic Cord

A simplified treatment algorithm for chronic scrotal content pain syndrome

Background

Chronic scrotal content pain (CSCP) is a devastating condition characterized by localized scrotal pain that persists for ≥ 3 months and interferes with daily activities. Approximately 2.5% of all urology outpatient visits are associated with CSCP. General urologists may have difficulty treating these patients because of uncertainties regarding the etiology and pathophysiology of CSCP. Therefore, we aimed to provide a simplified diagnostic and treatment approach for CSCP by subdividing it into distinct categories.

Materials and methods

We systematically reviewed the published literature in the PubMed, MEDLINE, and Cochrane databases for all reports on CSCP diagnosis and treatment using the keywords "chronic scrotal content pain," "testicular pain," "orchialgia," "testicular pain syndrome," "microdenervation of the spermatic cord," "post-vasectomy pain syndrome," "post-inguinal hernia repair pain," "testialgia," and "pudendal neuralgia." This review included only CSCP-related articles published in English language.

Results

We subdivided CSCP syndrome into 5 clinical presentation types, including hyperactive cremasteric reflex, pain localized in the testicles, pain in the testis, spermatic cord, and groin, pain localized in the testicles, spermatic cord, groin, and pubis, and pain in the testicles, spermatic cord/groin, and penis/pelvis. Treatments were adjusted stepwise for each type and section. We included more information regarding the role of pudendal neuroglia in CSCP syndrome and discussed more options for nerve blocks for CSCP. For microsurgical spermatic cord denervation failure, we included treatment options for salvage ultrasound-guided targeted cryoablation, Botox injections, and posterior-inferior scrotal denervation.

Conclusions

Different CSCP subtypes could help general urologists assess the appropriate diagnostic and treatment approaches for scrotal pain management in daily practice.

Scrotal Pain after Varicocelectomy: A Narrative Review

Varicocele is a frequently encountered urological disorder, which has a prevalence rate of 8 to 15% among healthy men. However, the incidence is higher in male patients with primary or secondary infertility, with up to 35 to 80% of varicocele cases occurring in this population. The clinical manifestations of varicocele typically include the presence of an asymptomatic mass that feels like a “bag of worms”, chronic scrotal pain, and infertility. Most patients with varicocele only undergo varicocelectomy after conservative treatments have failed. Unfortunately, some patients may still experience persistent scrotal pain due to a recurrence of varicocele, the development of hydrocele, neuralgia, referred pain, ureteral lesions, or nutcracker syndrome. Therefore, clinicians should consider these conditions as potential causes of postoperative scrotal pain, and take measures to address them. Several factors can assist in predicting surgical outcomes for patients with varicocele. Clinicians should consider these factors when deciding whether to perform surgery and what type of surgical intervention to use. By doing so, they can increase the likelihood of a successful surgical outcome and minimize the risk of complications such as postoperative scrotal pain.

Chronic scrotal pain: Pathogenesis, clinical phenotypes and modern treatment concept (clinical lecture)

Chronic scrotal pain (CSP) is a general term, which defines variety of problems causing discomfort or pain in the scrotum, which can be caused by the problems with testicles and other structures of the scrotum: epididymis, vas deferens, paratesticular structures. For a practicing urologist, the diagnosis and treatment of chronic scrotal pain is always a difficult task due to the many reasons for its appearance and the variety of clinical symptoms. CSP is a widespread but poorly understood condition, the etiology of which often can not be identified. Pain localized in the scrotum makes up 38.8 % of all cases of chronic men’s pelvic pain. From 2.5 to 4.8 % of all visits to the urologist relate to CSP syndrome. Primary scrotal pain syndrome is not associated with infection or other local pathological processes that could cause pain. The treatment of chronic scrotal pain is challenging because the pain often does not react to the traditional treatments.

The purpose of this lecture is to draw the attention of urologists, general practitioners, and everyone who is interested in the problem of treating chronic scrotal pain to the possibilities of modern medicine in solving this multidisciplinary problem.

Cryoablation of the penile nerves for chronic penile pain

We present a unique case of a 39-year-old male with a 20-year history of chronic penile pain. Unfortunately, there are currently very limited reports on how best to manage chronic penile pain, as chronic penile pain is a diagnosis of exclusion without any apparent disease. Here, we describe our patient's clinical presentation of chronic penile pain, history of previously failed medical and procedural treatments, and eventually completion of cryoablation of the penile nerves. In this case study, we demonstrated that targeted cryoablation of the penile nerves is a potential treatment option for chronic penile pain that failed medical management. We also discuss the anatomy and innervation of the penis as it relates to sensation of chronic penile pain and subsequent cryoablation of the penile nerves.

Surgical management of chronic scrotal pain: a review of the current literature

Chronic scrotal pain may be due to an identifiable cause, may be multifactorial, or may be idiopathic. Successful treatment often requires multimodal therapy with a multidisciplinary approach. Conservative options may be offered initially, but if symptoms fail to improve with conservative interventions, more invasive therapies may be required. A nerve block may be attempted and patients who experience improvement in pain following nerve blocks may be good candidates for surgical denervation of the spermatic cord. Alternative surgical treatment options including proximal nerve blocks, neuromodulation, cryoablation, vasectomy reversal, varicocelectomy, and even orchiectomy have been described. The aim of this review is to discuss the treatment options for chronic scrotal pain with a focus on surgical treatment options.

Non-pharmacological treatments for chronic orchialgia: A systemic review

Objective

: To review the outcomes of various therapeutic modalities that can be offered to patients with chronic orchialgia (CO) after failed conservative treatment.

Methods

: A literature search was conducted using the PubMed and MEDLINE databases searching for articles exploring different CO treatment modalities. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach was used to report the results of the literature search.

Results

: A total of 34 studies were included for qualitative analysis. Most of the studies explored microsurgical spermatic cord denervation (MSCD; n = 19). Eight studies involved devices and interventions directed at blocking nerve sensations (pulsed radiofrequency stimulation, n = 5; transcutaneous electrical nerve stimulation, n = 1; cryoablation, n = 1; and mechanical vibratory stimulation, n = 1). Five studies reported on vasectomy reversal as a modality to relieve post-vasectomy pain syndrome (PVPS), while two studies explored the outcomes of orchidectomy on pain relief in patients with CO.

Conclusion

: Several treatment methods are available in the urologist’s armamentarium for the treatment of CO. MSCD appears to be an appealing treatment modality with encouraging outcomes. Neuropathic pain can be managed with a number of relatively non-invasive modalities. Vasectomy reversal is a sound treatment approach for patients with PVPS and ultimately orchidectomy is a terminal approach that can be discussed with patients suffering from intractable pain.

Current trends and therapies in orchialgia management

The management of pain is a complex condition that will be encountered by most practicing clinicians. In the genitourinary community, testicular pain may be classified as acute or chronic. Initial evaluation of chronic groin and scrotal content pain (CGSCP) begins with a detailed history and physical examination to elucidate the presenting pathology. Multiple therapy algorithms have been proposed with no definitive consensus; however, most begin with conservative intervention and medical management prior to advancing to more invasive procedures. Surgical approaches may range from reconstruction, as in vasovasostomy for post-vasectomy pain syndrome, to excision of the offending agent, as in epididymectomy. This review seeks to focus on chronic pain in the genitourinary community and review techniques of pain management in the current intervention for orchialgia, as well as identify future methods of treatment.

Gold Standard Care of Chronic Scrotal Pain

INTRODUCTION

Chronic scrotal pain (CSP) can be a debilitating condition for patients and is often difficult to characterize.

METHODS

A review of literature was performed using Embase, Cochrane and Medline databases in the period 1.January 2010 to 1.January 2021. We found 132 articles, and the authors screened abstract and references. Thirty-seven articles are included after removing duplicates.

RESULTS

This review presents a variety of medical and surgical treatment options for CSP such as spermatic cord blocks (36-80% success rate), microsurgical denervation of the spermatic cord (76-100% success rates), Botox (56% success rate), targeted ilioinguinal and iliohypogastric peripheral nerve stimulation, and radical orchiectomy (55-75% success rate).

CONCLUSION

An overview of various treatment options, both non-surgical and surgical are provided, with the aim of establishing what may be the best treatment option for CSP.

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

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. 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.

A Review of the Management of Chronic Scrotal Pain

Chronic scrotal pain (CSP) is a common and poorly understood medical condition that significantly affects individuals' quality of life. Many patients seek evaluation and management of their symptoms from multiple physicians. Our review aims to address diagnostic modalities, clinical evaluation, and surgical and non-surgical management. We conducted a computerised detailed search of the PubMed, Medline, Embase and Cochrane databases for reports pertaining to CSP using the Medical Subject Headings keywords 'chronic scrotal pain', 'testicular pain' and 'orchialgia', and we included in the review those that fulfilled the inclusion (adult male with CSP presenting with the criteria of CSP ) and exclusion (extra-scrotal pain) criteria. After the direct causes of CSP were identified by reviewing the clinical evaluations (history taking and examination are mandatory) and the diagnostic evaluations (urine analysis is crucial and ultrasound can be helpful), the most-used medical and non-surgical treatments for CSP were tricyclic antidepressants (success rate of up to 66.6%) and spermatic block (success rate of more than 90%), and the most-used surgical procedure was microsurgical denervation of the spermatic cord (success rate of up to 70%). The evidence currently available remains rare and of low quality, making it difficult to strongly recommend individual treatment options. However, multimodal treatment modalities using physical therapy and psychotherapy may help patients and provide useful tools for coping with this condition. There are also useful non-surgical and surgical options for CSP that depend on the patient's state, the severity of the complaint and what options have already been tried.

Percutaneous cryoanalgesia for pain palliation: Current status and future trends

Cryoanalgesia, otherwise termed cryoneurolysis, refers to application of extreme cold upon peripheral nerves for palliation of pain associated to nerve lesions or biomechanical syndromes of neoplastic and non-neoplastic substrate. Application of cryoanalgesia initiates a cascade of pathophysiologic events interrupting nerve conduction of painful stimuli without irreversible nerve damage. Cryoanalgesia is considered a safe procedure with minimal risk of complications when performed with percutaneous approaches under imaging guidance. In the era of an opioid overdose crisis, cryoanalgesia can be proposed as an alternative aiming at controlling pain and improving life quality. Imaging guidance has substituted open surgical and nerve stimulation approaches in nerve identification, significantly contributing to the minimally invasive character of percutaneous approaches. Ultrasound or computed tomography can serve as low cost, ideal guiding techniques due to their abilities for precise anatomic delineation, high spatial resolution and good tissue contrast. The purpose of this review is to become familiar with the most common imaging guided percutaneous cryoanalgesia indications, to learn about different technical considerations during performance providing the current evidence. Controversies concerning products will be addressed.

Management of Chronic Orchialgia: Challenges and Solutions - The Current Standard of Care

INTRODUCTION

Chronic scrotal content pain (CSP) or chronic orchialgia can be debilitating for patients and difficult to treat. There is a paucity of structured treatment algorithms to approach this difficult condition.

METHODS

A review of the literature was performed. Conservative treatment options are presented and then targeted surgical interventions that the urologist may perform are then presented in a structured algorithm format. Many of these patients may obtain a significant reduction in pain with some of these treatments.

RESULTS

This review presents the pathophysiology, a new assessment tool, and various treatment options available for CSP patients, such as targeted spermatic cord blocks, targeted and standard microsurgical denervation of the spermatic cord (77-100% success rates), ultrasound-guided peri-spermatic cord and ilioinguinal cryoablation (59-75% success rates), scrotox (botox) (56-72% success rates), targeted ilioinguinal and iliohypogastric peripheral nerve stimulation (72% success rate), radical orchiectomy (20-75% success rate), targeted robotic-assisted intra-abdominal denervation (71% success rate) and vasectomy reversal (69-100% success rates).

CONCLUSION

A structured and evidence-based approach to help urologists manage patients with chronic orchialgia or scrotal content pain is presented.