Chronic orchialgia: epidemiology, diagnosis and evaluation

Evaluation of Botox treatment in patients with chronic scrotal pain: Protocol for a randomized double-blinded control trial

Background

Chronic scrotal pain is a common condition with a prevalence of 2.5-4.8% in male outpatients. Up to 40% of these patients report depressive symptoms and many feel isolated. Minimal invasive treatment is lacking, while spermatic cord injections of Botox® (BTX) have been proposed to offer long-term pain relief.

Study Design

This research protocol comprises a prospective multicentre, randomized, double-blinded clinical trial drawing patients from other urological departments in the region of Southern Denmark.

End Points

The primary end point will be reduction in pain evaluated by visual analogue score for pain at 3 months. Secondary end point will be length of effect of BTX injections along with changes in quality of life.

Patients and Methods

The study will include 50 patients for randomization to either spermatic cord block with 100 IE BTX or sterile saline. All patients will prior to randomization undergo physical examination and will be asked to fulfil multiple questionnaires regarding pain and impact in daily life, that is, (1) visual analogue score for pain, (2) quality of life (EQ-5D-5L), (3) Chronic Prostatitis Symptom Index (NIH-CPSI), (4) ICD-10 depression questionnaire (MDI), (5) Likert global assessment scale, and (6) International Index of Erectile Function questionnaire. Physical examination and fulfilment of the questionnaires will be repeated multiple times throughout the study period of 12 weeks. After this time point, patients will be unblinded, and the control arm will be given the opportunity of cross-over.

Turkish validation of the chronic orchialgia symptom index and its association with the visual analog scale

OBJECTIVE

To conduct a translation and validation study of the Chronic Orchialgia Symptom Index (COSI), which has 12 questions in three domains pain (P), sexual symptoms (SS), and quality of life (QoL), in the Turkish language.

MATERIAL AND METHODS

The study included a total of 175 patients diagnosed with chronic scrotal content pain (CSCP) between January 2023 and January 2024. In addition to demographic data, the scores obtained on the COSI questionnaire and Visual Analog Scale (VAS) were recorded. Internal consistency was assessed using Cronbach alpha coefficients. Reliability was evaluated using the test-retest correlation method.

RESULTS

The mean age of the patients was 37.2 ± 14.1 years and the median (IQR) duration of pain was 5.5 (9) months. The median total COSI score was determined as 13 (13) and the median subscores were 7 (7) for P, 1 (2) for SS, and 5 (6) for QoL. The test-retest correlation coefficient for each item was determined to be higher than r = 0.80 (p < 0.001). The Cronbach alpha values for the subscores were 0.80 for P, 0.71 for SS, and 0.80 for QoL. There was determined to be a statistically significant positive correlation between the VAS score and the COSI P, SS, QoL, and total scores (r: 0.63, p < 0.001; r = 0.32, p < 0.001; r = 0.56, p < 0.001; r = 0.59, p < 0.001, respectively). The optimal cutoff point of the COSI total score was determined to be 16.5 points (AUC:0.77, p < 0.001) for the determination of patients experiencing severe pain (⩾ 7.5) according to the VAS score.

CONCLUSION

The Turkish version of the COSI questionnaire is a valid, reliable, and repeatable questionnaire that can be used to evaluate the effects of symptom severity in patients with CSCP.

Promoting 'testicular awareness': Co-design of an inclusive campaign using the World Café Methodology

INTRODUCTION

Testicular cancer is the most common cancer in men aged 15-44 years in many countries. Most men with testicular cancer present with a lump. Testicular symptoms are more likely to occur secondary to benign diseases like epididymo-orchitis, a common sexually transmitted infection. Gender and sexual minorities are at an increased risk of testicular diseases and health disparities. The aim of this study was to co-design an inclusive community-based campaign to promote testicular awareness.

METHODS

This study uses the World Café methodology. Participation was sought from Lesbian, Gay, Bisexual, Transgender and Queer+ friendly organisations, testicular cancer survivors, health policy makers, media and marketing experts and graphic designers. Participants engaged in three rounds of conversations to co-design the campaign. Data were collected using drawing sheets, artefact cards, sticky notes, coloured markers and a voice recorder. Deductive thematic analysis was conducted.

RESULTS

Seventeen individuals participated in the study. Six themes emerged from the analysis as follows: (i) online communication; (ii) offline communication; (iii) behavioural targeting and education; (iv) campaign frequency and reach; (v) demographic segmentation; and (vi) campaign identity. The use of social media for campaign delivery featured strongly in all conversations. Participants also recommended offline communication using posters and radio/television advertisements to scale up the campaign and achieve wider reach. Advertisements to overcome embarrassment surrounding testicular health were particularly recommended. Participants emphasised that campaign delivery must be dynamic whilst ensuring that the health-promoting messages are not diluted or lost. They stressed the importance of being inclusive and tailoring the campaign to different age groups, gender identities and sexual orientations.

CONCLUSIONS

Study recommendations will be used to design and deliver the campaign. Future research will be needed to evaluate the feasibility, acceptability, cost and effect of the campaign on promoting testicular awareness and early detection of testicular diseases.

PATIENT OR PUBLIC CONTRIBUTION

A participatory research approach was used to co-design the campaign with members of Lesbian, Gay, Bisexual, Transgender and Queer+ (LGBTQ+) friendly organisations, LGBTQ+ student bodies, LGBTQ+ staff networks, LGBTQ+ sports clubs, men's health organisations, testicular cancer survivors, health policy makers, media and marketing experts and graphic designers.

Metachronous bilateral spontaneous spermatic vein thrombosis: A rare cause of orchialgia

Scrotal pain and swelling are common presentation, the prompt evaluation and diagnosis is needed due to wide range of causes, uncommon causes of orchialgia should be kept in mind whenever there is no clear diagnosis. Spermatic vein thrombosis usually presents with orchialgia along with episodes of acute exacerbation of pain. The diagnosis is challenging and need high index of suspension and detailed radiological evaluation. We present a case of metachronous bilateral unprovoked spermatic vein thrombosis treated conservatively with anticoagulation with good response and resolution of symptoms.

Orchialgia After Living Donor Nephrectomy: An Underreported Entity

Laparoscopic donor nephrectomy (LDN) offers advantages to the donor. The reported incidence of testicular pain after LDN varies in the literature ranging from 3% to 55%.

Methods

A survey was sent to 322 male LDN patients who donated from February 5, 2009, to February 5, 2019. The survey assessed if the donor had testicular pain or saw an additional medical professional after donation.

Results

Of the 322 surveyed, 147 (46%) responses were received. Of those who had a left nephrectomy, 39% had testicular pain; 23.8% of those patients had testicular swelling in addition. Of those who had pain, laterality of kidney donated did not impact if the patient had pain, pain onset, pain level, or pain duration. Of those who donated their right kidney, 35% had testicular pain, and 16.7% of those patients reported testicular swelling in addition. Twenty-seven symptomatic patients sought additional medical care for the testicular symptoms postdonation. Seven (25%) had hydroceles, 2 (7%) had testicular cysts, 1 had a urinary tract infection, and 16 (59%) had reassurance or no additional procedures provided.

Conclusions

Our results suggest that orchialgia is not as uncommon as previously thought and may be one of the most common minor complications experienced by male donors.

Varicoceles: Overview of Treatment from a Radiologic and Surgical Perspective

A testicular varicocele is the result of the expansion of the venous pampiniform plexus of the scrotum. Often painless, a significant number of patients experience orchialgia, swelling, testicular atrophy, and abnormalities in spermatic parameters. Treatment of symptomatic varicocele involves a radiologic or surgical intervention to obstruct the reflux of venous drainage. Testicular anatomy, diagnostic evaluation and imaging, options for surgical intervention, and a step-by-step description of retrograde embolization and antegrade scrotal sclerotherapy are discussed. Furthermore, included is an overview of postprocedural management and patient outcomes for radiological interventions, and the most up-to-date evidence on the efficacy of varicocele treatments as well as how they compare to each other.

Diagnostic pitfall in a large cell lung cancer with testicular metastasis synchronous malignant pleural mesothelioma patient: A case report

Large cell lung cancer metastases to the testis are scarce, although it is the most common malignancy and the most common site of metastases for breast, colorectal and kidney cancers. We hereby report a 28-year-old male patient admitted to our hospital with a chief complaint of scrotal enlargement, accompanied by chest pain and progressive dyspnea. The definite diagnosis was malignant pleural mesothelioma with the synchronous occurrence of large cell lung cancer with testicular metastasis. Sophisticated clinical manifestation of symptoms led to a time-consuming diagnosis, while the patient's condition deteriorated rapidly. Herein, we present this case to share our hard-learnt experience to increase clinician awareness and contribute to the information in the literature.

The incidence of testicular torsion and testicular salvage rate in Korea over 10 years: A nationwide population-based study

PURPOSE

We performed a nationwide epidemiological study of testicular torsion using the National Health Insurance System database for the entire male population of Korea.

MATERIALS AND METHODS

Age, sex, socioeconomic status, regional information, and diagnostic codes were retrieved from January 2009 to December 2019. To clearly identify the diagnosis of testicular torsion, patients who had not undergone orchiectomy or orchiopexy were excluded from the study. Multivariable logistic regression models were used to analyze the association between demographic characteristics and testicular loss.

RESULTS

The overall incidence of testicular torsion in males was 2.02 cases per 100,000 person-years and 6.99 cases per 100,000 person-years in males under 19 years of age. Testicular torsion most commonly occurred either in infancy or adolescence. The total testicular salvage rate was 75.22% and highest in children at 79.91%. The rate of orchiectomy was high in infancy and in the oldest patients. We determined that age distribution was related to the risk of testicular loss.

CONCLUSIONS

This study is the first nationwide epidemiological study of testicular torsion, which contains the entire Korean population. Although the testicular salvage rate in Korea was higher compared to other countries, it is necessary to educate males under 19 years of age on the seriousness of acute testicular pain to minimize the possibility of testicular loss.

Functional histology of human scrotal wall layers and their overlooked relation with infertility: a narrative review

Male infertility currently contributes to nearly half of the reported infertility cases. Scrotal wall layers play a cardinal role in regulating testicular physiology. However, few studies have focused on the functional histology of these layers and their relations with infertility in humans. The objective of the present narrative review is to collate novel insights into the functional histology of the human scrotal wall layers and their relation with infertility. The data was extracted from articles published between 1946 and 2021. The study was performed between January and December 2021. 71 original studies have been included in this review. Despite the fact that few studies have presented detailed functional histology of the human scrotal wall layers, this narrative review elucidates the possible influence of scrotal histology on infertility. Scrotal wall layers-associated pathologies may induce infertility by various mechanisms. They can impose mechanical forces that may affect the testicular histology and stimulate testicular inflammation. Moreover, they may induce testicular hyperthermia. Various unanswered clinical questions have been identified in this narrative review. More clinical studies are needed to assess the effect of alterations in the components of the scrotal wall layers on fertility (e.g., due to the exposure to metabolic and/or psychological stressors). In addition, testing the effectiveness of various pharmacological/surgical interventions to treat scrotal wall layers-associated pathologies will provide more insights into infertility treatment.

Postvaricocele Embolization Pain Syndrome: A Case Series Report and Review of Current Treatment Strategies

BACKGROUND

Orchialgia is not an uncommon complaint among men with varicocele, but postvaricocele embolization-related testicular pain has not been widely investigated. This study evaluates the phenomenon of postvaricocele embolization pain (PVEP) syndrome and examines the current strategies to treat this unusual complication.

METHODS AND MATERIALS

A prospectively collected database of patients with PVEP who presented to a tertiary center was analyzed between January 2011 and January 2020 following internal ethics approval. Patient demographics, including other complications related to embolization, analgesic requirements, and pain scores (on a 10-point visual analog score), treatment strategies, Patient Global Impression of Improvement (PGI-I) score and overall satisfaction score (on a 5-point scale), were reviewed. All patients were reviewed for a minimum of 12 months.

RESULTS

A total of 20 men with a mean age of 33.8 (18-45) years old, presented with PVEP over 10 years. Most men received embolization on an average of 26.6 (18-48) months. The reasons for varicocele embolization include either isolated or combined orchialgia (15 men), subfertility (5 men), and cosmesis (6 men). Eighteen (90%) men underwent microscopic spermatic cord denervation (MSCD) and 2 patients elected for conservative measures. The average pain scores pre-MSCD and post-MSCD were 6.9 (4-9) and 1.4 (0-4) (p<0.001) with a significant reduction in analgesia requirements. Immediate improvement in pain score was reported in all the patients and this persisted at the 12 months review. Most men reported a high satisfaction score (of 4/5) and only one patient reported no change in symptoms after MSCD.

CONCLUSION

PVEP is a unique complication and patients should be counseled on the potential risk of persistent orchialgia following embolization for varicocele. The MSCD appears to be an effective treatment option with high success and satisfaction rates.

Microsurgical Denervation of the Spermatic Cord: A Historical Perspective and Recent Developments

INTRODUCTION

The management of chronic scrotal pain is long and varied, with historical treatment algorithms typically ending with orchiectomy. Microsurgical denervation of the spermatic cord (MDSC) is a testicle-sparing option for patients who have failed conservative treatment options and over its forty-year history has seen many technical refinements.

OBJECTIVES

To review the history and development of MDSC and discuss the outcomes of different surgical techniques.

METHODS

A literature review using PubMed and Google Scholar was conducted to identify studies pertaining to surgical treatment of CSP, MDSC, and outcomes. Search terms included "chronic," "scrotal pain," "orchialgia," "spermatic cord," "denervation," and "microsurgery."

RESULTS

We included 21 case reports and series since the first seminal paper describing MDSC technique in 1978. Additional studies that challenged existing conventions or described novel techniques are also discussed. The current standard procedure utilizes a subinguinal incision and a surgical microscope. Open, robotic, and laparoscopic approaches to MDSC have been described, but access to minimally invasive instruments may be limited outside of developed nations. Pain reduction following preoperative spermatic cord predicts success of MDSC. Methods for identifying and preserving the testicular and deferential arteries vary depending on surgeon preference but appear to have comparable outcomes. Future developments in MDSC involve targeted denervation, minimizing collateral thermal injury, and alternative techniques to visualize arterial supply.

CONCLUSION

For patients suffering from CSP, MDSC is a well-studied technique that may offer appropriately selected patients' relief. Future investigation comparing targeted vs full MDSC as well as in vivo study of new techniques are needed to continue to improve outcomes. Sun HH, Tay KS, Jesse E, et al. Microsurgical Denervation of the Spermatic Cord: A Historical Perspective and Recent Developments. Sex Med Rev 2022;XX:XXX-XXX.

lncRNA and mRNA sequencing of the left testis in experimental varicocele rats treated with Morinda officinalis polysaccharide

Varicocele is a common disease of the male reproductive system. Morinda (M.) officinalis is a Chinese herbal medicine, whose main bioactive component M. officinalis polysaccharide (MOP) is believed to have a therapeutic effect on varicocele; however, the underlying molecular mechanisms of this effect are poorly understood. In the present study, 24 rats were randomly divided into three groups: i) Control group; ii) experimental varicocele group; and iii) 300 mg/kg MOP administration group. Analysis of mRNA and long non-coding RNA (lncRNA) expression in rat left testicular tissue was performed. The results suggested that a total of 144 mRNAs and 63 lncRNAs, 63 mRNAs and 148 lncRNAs, and 173 mRNAs and 54 lncRNAs were differentially expressed between the varicocele non-treatment and control groups, the varicocele treatment and varicocele non-treatment groups, and the varicocele treatment and control groups, respectively. Following validation by reverse transcription-quantitative PCR, the Yip1 domain family member 7 (YIPF7) gene was identified as a key mediator of varicocele pathogenesis and repair effect of MOP. Additionally, genes such as purinergic receptor P2X 4 (P2RX4), transmembrane protein 225B (TMEM255B) and Wnt family member 9B (WNT9B) were confirmed to be differentially expressed between the varicocele non-treatment and control groups. We hypothesize that TMEM255B could be a potential novel diagnostic biomarker for varicocele; WNT9B and P2RX4 likely play notable roles in the pathophysiology of the disease through the Wnt signaling pathway and regulation of transmembrane ion channels, respectively. In summary, the present study delineated the molecular mechanisms underlying varicocele pathogenesis and the therapeutic effect of MOP, identified a potential novel diagnostic marker and therapeutic target for varicocele, and provided feasible directions for further studies in the future.

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.

Chronic Orchialgia Stemming From Lumbar Disc Herniation: A Case Report and Brief Review

Chronic orchialgia can be the result of pathological processes of the scrotal contents or stem from non-intrascrotal structures. Successful pain management depends on identifying the source of localized or referred pain. This is a case report of a 39-year-old male sports coach who presented with low back pain, right orchialgia, and sciatica refractory to conservative management. Magnetic resonance (MR) imaging revealed disc protrusion at L3/L4 and L4/L5 levels. Positive outcomes in relieving back and testicular pain were obtained after a total of 30 chiropractic sessions over a 9-week period. The evidence of the subjective improvement was corroborated by regression of the herniated discs documented on the repeat MR imaging. While chronic orchialgia is not an uncommon problem for men of all ages, it has seldom been described in association with lumbar discogenic disease. The current study provided preliminary support for a link between orchialgia and lumbar disc herniation. Chiropractic manipulation had provided a mechanistic alleviation of noxious lumbar stimuli, leading to symptomatic and functional improvements.

Is there any association of COVID-19 with testicular pain and epididymo-orchitis?

AIMS

This study aims to analyse the novel Coronavirus disease- (COVID-19) related testicular pain in hospitalised patients because of COVID-19 and to review as an aetiological factor for epididymitis, orchitis or both.

METHODS

A total of 91 patients were included in the study. A questionnaire was formed for the questioning of testicular pain or epididymo-orchitis in patients with COVID-19. Demographics and past medical history was also recorded. Patients' neutrophil and lymphocyte counts, neutrophil-lymphocyte ratios (NLR), C-reactive protein (CRP) levels and D-dimer values were recorded. Patients with COVID-19 were divided into two groups according to absence or presence of testicular pain or epididymo-orchitis as group 1 and group 2. All results were compared for both groups.

RESULTS

The median age of patients was similar in both groups. Testicular pain was occurred in 10.98% of the patients. Clinical presentation of epididymo-orchitis was diagnosed in only one patient. No statistically significant difference was reported in terms of patients' age, levels of CRP and D-Dimer or NLR and results of questionnaire form queries between the two groups (P > .05).

CONCLUSION

Testicular pain was observed more frequently in hospitalised COVID-19 cases. While no inflammation marker which is related to predict of testicular pain or epididymo-orchitis was found in patients with COVID-19.

Microscopic spermatic cord denervation for chronic orchialgia/chronic scrotal content pain: operative outcomes and predictors of failure

Background

To describe our institutional outcomes with microscopic spermatic cord denervation (MSCD) for chronic scrotal content paint (CSCP) and identify predictors of treatment failure.

Methods

Retrospective chart review was performed to identify all MSCD performed by two surgeons at a single institution from 2010–2019. Patient demographic data and operative outcomes were collected. Patients were excluded from analysis if no post-operative follow up was available. Success was defined as complete resolution of bothersome pain. Multivariable logistic regression was utilized to identify predictors of treatment failure.

Results

During the study period, 101 patients were identified in which 113 MSCD procedures were performed. Final analysis included 103 procedures across 93 patients. Mean age was 41.8 years (SD 13.2), mean BMI was 29.2 kg/m² (SD 5.96) and median months of pain preceding surgery were 24 (range, 3–300 months). Overall, 75/103 (73%) MSCD were successful. Of the failures, 5 patients had recurrence of pain greater than 6 months after surgery. Only the presence of pelvic floor muscle spasm (PFMS) independently predicted MSCD failure (OR 3.95, P=0.02). 9 of 19 (47%) patients with PFMS experienced treatment failure, while 19 of 84 (23%) without PFMS experienced failure.

Conclusions

MSCD offers a therapeutic option for patients with refractory CSCP. The presence of PFMS is associated with lower surgical success rates. Patients with pre-operatively identified PFMS should be counseled regarding a higher risk of treatment failure.

Spinal Cord Stimulation for Visceral Pain: Present Approaches and Future Strategies

INTRODUCTION

The introduction of successful neuromodulation strategies for managing chronic visceral pain lag behind what is now treatment of choice in refractory chronic back and extremity pain for many providers in the United States and Europe. Changes in public policy and monetary support to identify nonopioid treatments for chronic pain have sparked interest in alternative options. In this review, we discuss the scope of spinal cord stimulation (SCS) for visceral pain, its limitations, and the potential role for new intradural devices of the type that we are developing in our laboratories, which may be able to overcome existing challenges.

METHODS

A review of the available literature relevant to this topic was performed, with particular focus on the pertinent neuroanatomy and uses of spinal cord stimulation systems in the treatment of malignant and nonmalignant gastrointestinal, genitourinary, and chronic pelvic pain.

RESULTS

To date, there have been multiple off-label reports testing SCS for refractory gastrointestinal and genitourinary conditions. Though some findings have been favorable for these organs and systems, there is insufficient evidence to make this practice routine. The unique configuration and layout of the pelvic pain pathways may not be ideally treated using traditional SCS implantation techniques, and intradural stimulation may be a viable alternative.

CONCLUSIONS

Despite the prevalence of visceral pain, the application of neuromodulation therapies, a standard approach for other painful conditions, has received far too little attention, despite promising outcomes from uncontrolled trials. Detailed descriptions of visceral pain pathways may offer several clues that could be used to implement devices tailored to this unique anatomy.

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.

Persistent orchialgia after laparoscopic living-donor nephrectomy: an underestimated complication requiring information adjustment

PURPOSE

Laparoscopic living-donor nephrectomy (LLDN) is the gold-standard procedure for kidney procurement. Ipsilateral orchialgia has barely been described. Some authors reported that ligation of gonadal vein (GV) above iliac vessel bifurcation could prevent orchialgia. We aimed to assess incidence and duration of orchialgia after LLDN in male donors despite distal ligation of GV.

METHODS

Patients who underwent LLDN from 2014 to 2017 were included. Standard procedure consisted in distal ligation of GV, close to the renal vein confluence and proximal ureteral ligation. Patients' demographics, per-operative data, and post-operative consultation reports were retrospectively reviewed. Orchialgia and scrotal symptoms were assessed through a non-validated questionnaire by phone interview.

RESULTS

Sixty-nine donors were included. Orchialgia incidence and testicular swelling were 31.9% (n = 22) and 15.9% (n = 11), respectively. Median symptom duration was 15.5 months. Orchialgia led to medical consultation in 41.7% (n = 10) of cases. All patients declared having been informed, prior to donation, about possible residual pain but not specifically orchialgia.

CONCLUSION

Orchialgia after LLDN affects more than 30% of donors, despite distal ligation of GV and led less than 50% of them to medical consultation, suggesting a large underestimation in clinical practice. Emphasis should be put on this complication during pre-donation information.

Terazosin or baclofen in young men with chronic orchialgia: A cohort study of 499 patients

PURPOSE

We aimed to investigate the comparative efficacy of terazosin and baclofen in young men with chronic orchialgia using National Institutes of Health Chronic Prostatitis Symptom Index measurement.

PATIENTS AND METHODS

Of 499 young men with chronic orchialgia, 255 received a daily 2 mg terazosin at bedtime and 244 received 10 mg baclofen during a period of 3 months. A daily 10-min hot-tub hip-bath rest was administered for all patients. Moreover, all patients with grade 3 and 18 patients with grade 2 varicocele underwent varicocelectomy. The National Institutes of Health Chronic Prostatitis Symptom Index score was assessed at baseline and 3 months later.

RESULTS

Both terazosin and baclofen groups experienced a significant reduction in mean National Institutes of Health Chronic Prostatitis Symptom Index score (24.78 and 24.81 at baseline to 19.68 and 19.60 after the treatment for terazosin and baclofen groups, respectively). However, there was no significant difference between the groups with regard to post-treatment National Institutes of Health Chronic Prostatitis Symptom Index score after adjustment for the pre-treatment score (p = 0.987). A total of 85 patients (33.4%) in terazosin group and 74 patients (30.3%) in baclofen group underwent varicocelectomy. Addition of the varicocelectomy to the treatment as a multimodal approach had no further improvement in the National Institutes of Health Chronic Prostatitis Symptom Index score.

CONCLUSION

Although a significant reduction was observed in mean National Institutes of Health Chronic Prostatitis Symptom Index score for both terazosin and baclofen groups, there was no significant difference between the treatments. Moreover, addition of varicocelectomy to terazosin or baclofen could not significantly decrease National Institutes of Health Chronic Prostatitis Symptom Index score; thus, varicocelectomy may not be appropriate for men who have some success with medical management. Further randomized studies are warranted.

Relationship between chronic testicular pain and mental health diagnoses

Background

Chronic testicular pain (orchialgia) has been defined as intermittent or constant unilateral or bilateral testicular pain that lasts 3 months or longer, significantly interfering with daily activities, and prompting the patient to seek medical attention. In many instances, the etiology of the pain is not identified. The contribution of psychological factors is unclear. The purpose of this study was to identify the categories of mental health (MH) diagnoses that are most frequently associated with orchialgia and determine if a correlation exists between MH diagnoses and orchialgia.

Methods

A retrospective review was performed to identify all adult patients within the San Antonio Military Health System with a new diagnosis of orchialgia from January 2005 to April 2015. Patients with acute pathology or recent inguinal/scrotal surgery were excluded. A comparative cohort of all men presenting with hydroceles within the same timeframe was obtained. The presence of coexisting MH diagnoses in both cohorts was then determined.

Results

Four hundred and forty-four men met the inclusion criteria for orchialgia, with 133 men presenting with hydroceles. The incidence of orchialgia increased significantly over the study period (P=0.001). MH diagnoses in the study population did trend upward over the years, but not significantly (P=0.063). MH diagnoses were not significantly higher in the cases compared to the controls (21.6% vs. 18.8%, P=0.479). The prevalence of anxiety was twice as high in the cases (9% vs. 4.5%), though not significantly (P=0.075). The prevalence of all MH diagnoses was significantly higher than in the general US population based on National Institute of Mental Health statistics.

Conclusions

The incidence of orchialgia rose significantly over time, but it was not significantly associated with MH diagnoses. These results may also be skewed by the overall higher percentage of MH diagnoses in the study population than in the general population.

Varicocele and Testicular Pain: A Review

Varicocele is the dilatation of the scrotal portion of pampiniform plexus and the internal spermatic venous system. About 15% of men suffer from scrotal varicocele and 2% to 10% of them complain of pain. The probable mechanisms for pain include compression of the surrounding neural fibers by the dilated venous complex, elevated testicular temperature, increased venous pressure, hypoxia, oxidative stress, hormonal imbalances, and the reflux of toxic metabolites of adrenal or renal origin. Testicular pain associated with varicoceles is typically described as a dull, aching, or throbbing pain in the testicle, scrotum, or groin; rarely, it can be acute, sharp, or stabbing. The management of testicular pain associated with varicocele starts with a conservative, non-surgical approach and a period of observation. Varicocelectomy in carefully selected candidates with clinically palpable varicocele resolves nearly 80% of all cases of testicular pain. Microsurgical techniques for varicocelectomy have gained popularity with minimal complication rates and favorable outcomes. The grade of varicocele, the nature and duration of pain, body mass index, prior conservative management, and the type of surgical method used, are predictors for the success of varicocelectomy.

Laparoscopic right varicocelectomy for chronic scrotal pain

Varicocele represents a common problem in young men with infertility or chronic scrotal pain and it is located on the left side in the vast majority of the cases. Right isolated varicocele is a quite rare entity, especially in middle-aged men and as the single pathology responsible for chronic pain. Further investigation might be needed to exclude other retroperitoneal or scrotal hidden lesions. Several surgical options are available for symptomatic patients with clinical varicocele including the laparoscopic approach of high ligation of the spermatic veins. We present a case of a 61-year-old patient treated with laparoscopic varicocelectomy for right chronic scrotal pain.

Validation of the Chronic Orchialgia Symptom Index for Men With Chronic Orchialgia/Chronic Scrotal Contents Pain

OBJECTIVE

To prospectively validate the chronic orchialgia symptom index (COSI), a newly created instrument with 12 questions in 3 domains (pain, sexual symptoms and quality of life).

METHODS

The COSI was given to 170 men with chronic orchialgia at 2 institutions. Seventy-eight men repeated the COSI before therapy and 42 repeated it after surgical therapy. Data was analyzed for test/retest internal reliability, internal consistency, floor and ceiling effects, construct validity, responsiveness and linear regression of all questions including age, duration, and prior surgeries.

RESULTS

The 170 men had a mean age of 44.3 (range 18-82) and median symptom duration of 24 months (3-420). About 22.4% had prior vasectomy, 12.4% had hernia repair, and 12.9% had other prior surgery. Mean total COSI was 20.0±7.7 (range 1-37) with subscores of pain 9.1±3.5 (0-17), sexual symptoms 1.82±1.5 (0-5) and quality of life 9.0±4.0 (0-15). Test/retest reliability was high with mean retest total score of 21.2±7.9 and intraclass correlation coefficient of 0.82. Internal consistency by Cronbach's alpha was 0.86. There were no floor or ceiling effects for total score. Construct validity showed all items contributed to a good fit model (P = .001). Patient age, duration, and prior surgeries did not influence COSI. Finally, the COSI was responsive to improvement after therapy (mean after treatment 13.5±9.8, P = .00001).

CONCLUSION

COSI is a valid and clinically relevant symptom index to assess severity of orchialgia symptoms and response to therapy in this challenging patient population.

Canadian Urological Association best practice report on chronic scrotal pain

N/A

Chronic Scrotal Pain

PURPOSE OF REVIEW

Chronic scrotal pain (CSP) is a common yet poorly understood condition, with significant impacts on overall quality of life. Many patients will have sought evaluation and management from multiple providers in an attempt to find a solution for their pain.

RECENT FINDINGS

Despite many emerging treatments for CSP and further understanding of the potential etiologies and pathophysiological basis of the condition, its natural history is poorly understood. It is also important to recognize the psychosocial impact of CSP and consider formal referral for psychological evaluation and treatment if the patient endorses significant psychiatric responses to pain. It is important to also recognize the neuropathic component of pain that may arise in patients with CSP. Neuropathic medications show promise as a narcotic-sparing pharmacological intervention. There are promising surgical options for CSP including microsurgical denervation of the spermatic cord. This article highlights the current best practice recommendations on the evaluation and management of chronic scrotal pain.

Histopathological pattern of testicular diseases in western Saudi Arabia

Objectives

To determine the histopathological pattern of testicular diseases among Saudi patients in Madinah, Saudi Arabia.

Methods

This retrospective histopathology-based study was conducted in a tertiary care hospital in Madinah, Saudi Arabia, from January 2006 to December 2017. The data collected were entered into MS-Excel and analyzed using the Statistical Packages for Social Sciences Version 19.

Results

Of the 199 testicular specimens received, 108 (54.3%) of the biopsies were taken for diagnostic test, while 91 (45.7%) were for therapeutic test. The male infertility was the only indication in the diagnostic group, accounting for 108 (54.3%) with a mean age of 28±7.9 years. Benign conditions of the testes were the most common indication in the therapeutic group accounting for 76 cases (38.2%), followed by 15 cases (7.5%) of testicular tumors. Hemorrhagic infarction from testicular torsion was the most common histologic patterns in benign testicular conditions group, accounting for 46 (23.2%) of the cases with a mean age of patients 32.1±8.1 years. Mixed non-seminomatous germ cell tumor was the most common primary tumor in 7 (3.5%) cases, followed by seminoma occurring in 5 (2.5%) cases. Mean ages for these patients were 33.7±8.1 years for primary tumor and 35.6±9.1 years for seminoma.

Conclusions

The pattern of testicular diseases on the basis of histopathology experience in the Madinah region appears to conform to world literature and KSA.

Development of a clinically relevant symptom index to assess patients with chronic orchialgia/chronic scrotal content pain

Background

The purpose of this study was to develop a candidate symptom index for men with an established diagnosis of chronic orchialgia.

Methods

Based on interviews with patients and providers, we developed a 70-item questionnaire that focused on seven areas of orchialgia symptoms: pain, location, urinary symptoms, sexual dysfunction, medical history and quality of life (QOL) impact. The questionnaire was completed by patients at two medical centers. Cluster analysis was performed with the software package R (3.2.1).

Results

A total of 113 men completed the survey. Median symptom duration was 12 months (range, 3-336 months). Outside the testicle, pain was felt in the spermatic cord (66%), groin (66%), penis (24%), suprapubic region (38%), flank (31%), thigh (32%), abdomen (36%) and perineum (35%). Bother scores were high only for testicle and spermatic cord pain. Urinary frequency was common (54%) but not bothersome. Sexual dysfunction was common: 55% had erectile dysfunction, 56% had decreased libido and 39% had painful ejaculation with high bother for all. By cluster analysis, QOL parameters clustered tightly with minimal pain level, pain at night, burning pain, distribution to spermatic cord and groin, erectile dysfunction and premature ejaculation.

Conclusions

Men with chronic orchialgia have a high incidence of associated symptoms. Most bothersome symptoms with highest QOL impact include burning pain, pain at night, radiation to groin and spermatic cord, erectile dysfunction and low libido. Based on these findings, we have created a candidate orchialgia symptom index with domains of pain, sexual symptoms and QOL that will undergo prospective validation.

Chronic Pelvic Pain: Assessment, Evaluation, and Objectivation

Chronic Pelvic Pain (CPP) and Chronic Pelvic Pain Syndrome (CPPS) have a significant impact on men and women of reproductive and nonreproductive age, with a considerable burden on overall quality of life (QoL) and on psychological, functional, and behavioural status. Moreover, diagnostic and therapeutic difficulties are remarkable features in many patients. Therefore evaluation, assessment and objectivation tools are often necessary to properly address each patient and consequently his/her clinical needs. Here we review the different tools for pain assessment, evaluation, and objectivation; specific features regarding CPP/CPPS will be highlighted. Also, recent findings disclosed with neuroimaging investigations will be reviewed as they provide new insights into CPP/CPPS pathophysiology and may serve as a tool for CPP assessment and objectivation.