Chronic scrotal pain: How you can assist patients

Daniel Shoskes, MDChronic orchialgia affects nearly 5% of men presenting to urology clinics, yet remains “one of the great understudied conditions in urology,” according to Daniel Shoskes, MD. In this interview, Dr. Shoskes discusses his evaluation of patients with scrotal pain, outlines his use of conservative treatments, and explains surgical approaches and how he decides whether to use them. Dr. Shoskes is professor of urology at Cleveland Clinic’s Glickman Urological & Kidney Institute and director of the Novick Center for Clinical and Translational Research. He was interviewed by Urology Times Editorial Consultant Philip M. Hanno, MD, MPH, clinical professor of urology at Stanford University School of Medicine, Stanford, CA.

Let me begin with a true anecdote to show the desperation of patients with chronic orchialgia. When I was a senior registrar in England 36 years ago, cases to be scheduled were put on 3x5 cards and the wait list was about 2 years for some elective surgeries. A 24-year-old man with intractable orchialgia who begged for bilateral orchiectomy was placed on the wait list in the hopes that symptoms would ultimately improve, with no one thinking he would ever come to bilateral orchiectomy. Unfortunately, the junior registrar pulled his card down to do the case because he was not familiar with the story and wanted to do an orchiectomy. Somehow, it went through the system. Does this surprise you?

It doesn’t surprise me on a number of levels, especially since I spent a couple of years in England, and I know how that system works. I’m not trying to pick on the British system.

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Chronic orchialgia is-and I believe remains-one of the great understudied conditions in urology. You can tell how understudied a condition is by the dismissive terms we use for it.

When I started working in the area of chronic prostatitis in the mid-1990s, the running joke was, “Who do you see for chronic prostatitis? The most junior person on faculty.” Along the same lines, the joke with orchialgia is, “Chronic orchialgia, what is it? Just another guy with ball pain.” There are descriptions in the military that that’s what people complain about when they want to get off of work. And yet, when you begin to see these patients, just as the women who were leaking urine and just as the men who had chronic prostatitis before them, they’re not all crazy, they’re not all faking. Many are very reasonable men with real pain and real impact on their quality of life. We owe it to them to study the condition, understand the phenotype of the problem, and come up with therapies to help them just as we do with other “sexier” areas in urology.

Next: "It’s probably only people with more of a specialty interest who even bother to code this as chronic orchialgia or chronic scrotal content pain."

A study published in the American Journal of Men’s Health (2013; 7:402-13) reported an estimated prevalence of chronic scrotal pain in all men presenting to urology clinics of 4.75% Up to 18.6% of these men never receive a satisfactory explanation for the cause of the pain. But no one really knows the true incidence. It’s a very big problem.

It’s very difficult to determine the prevalence when you look at coding. How is this coded? I think just as often as not it may be called epididymitis in a person who has nothing wrong with their epididymis and doesn’t have a tender epididymis. It’s probably only people with more of a specialty interest who even bother to code this as chronic orchialgia or chronic scrotal content pain.

That’s a good segue to my next question. Chronic orchialgia seems so different than what we would consider chronic pelvic pain syndrome (CPPS) in men, non-bacterial prostatitis (NIH category III). Do you think it should be considered a part of this complex, or should it be separated out?

From the beginning of the NIH studies of CPPS, it was always an exclusion criterion for men with isolated testicular pain out of concern that we would be bringing in a different group. I think there is no question that many men with CPPS have, in addition to their other symptoms, pain in their testicles, and there can be common etiologies, in particular: pelvic floor spasm, which can cause perineal but also testicular pain, and neuropathy, which, if it affects the nerves in the region can also affect the testicles. But I would hesitate to lump men with pure testicular pain together with those with CPPS because CPPS is so often a systemic condition and I think it would confuse rather than help the diagnosis and treatment algorithm.

Please discuss the different etiologies of the condition and whether they guide the treatment algorithm.

True chronic orchialgia or chronic scrotal content pain by definition is a diagnosis of exclusion. Many men will have a prior history of what sounds like a true infected or inflammatory epididymis. We include men with the so-called post-vasectomy pain syndrome; whether the prior vasectomy qualifies them as orchialgia or not is a semantic discussion. We usually include them with the others. Some men have had prior inguinal surgery such as hernia repairs or orchidopexy, but at least 40% have no identifiable initial insult.

Next: "One of the dangers in treating post-vasectomy pain is using a surgical intervention too soon."

I’ve seen many men with chronic orchialgia after vasectomy. The literature suggests it may occur in up to 15% of these men. How do you advise men considering vasectomy, and how do you approach the problem post vasectomy?

You have to explain to the person having a vasectomy that pain is common, it lasts for varying amounts of time, and that some men can have persistent pain for weeks and some pain for months. I think it’s much rarer to have pain that goes on beyond a 6-month period. That’s probably in the one in 1,500 range, although again, statistics are poor in this.

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One of the dangers in treating post-vasectomy pain is using a surgical intervention too soon. I think it’s important to give patients at least 6 months of supportive measures to see whether healing will take its course; you know that they won’t develop an ongoing pain syndrome.

When someone comes in with orchialgia of undetermined etiology, how do you approach it? How do you evaluate it?

I go back to the basics of a full history and physical. Interestingly, in many men who have been treated recently for epididymitis, I find that they’ve have been treated with antibiotics that are not guideline suggested. For instance, Cipro is not a recommended antibiotic for epididymitis, even though Levaquin and ofloxacin are.

Why is that?

I believe it has to do with penetration into the epididymis and with coverage of particular bacteria. That’s pure CDC guidelines; you can download it off the CDC website today. I see many men with persistent pain who have been treated with Cipro who, when they’re then switched to a guideline antibiotic such as doxycycline or Levaquin, their pain resolves. You can’t assume just because they’ve seen several urologists before you that all of these points have been examined.

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It’s very important to assess pelvic floor spasm and to do a rectal exam, which is sometimes surprising and embarrassing to the 21-year-old who is coming to you for their testicular pain. A significant proportion will have pelvic floor spasm and trigger points that you can palpate that will absolutely reproduce their pain. It’s very important to identify these men, first because if you proceed with some surgical treatment they’re much more likely to fail and second, there is excellent effective treatment available in the form of pelvic floor physical therapy with some adjunctive treatments that can be curative in 80% plus.

Next: What are the standard analgesic and neuropathic pain medications that you try?

What are the standard analgesic and neuropathic pain medications that you try?

We like to try something with an anti-inflammatory component, so we often use the nonsteroidal anti-inflammatories. For men with burning pain that sounds as though it could be neuropathic, a neuroleptic such as pregabalin or amitriptyline can often be effective.

How often is a chronic identifiable infection the cause of orchialgia, and does it respond to antibiotics? Without culture documentation, what do you recommend for empiric therapy?

At least in the United States, for conventional bacteria I suspect that that is rare and when present is usually associated with an epididymal abnormality both on palpation and with ultrasound. Again, I think that the guideline-recommended antibiotics are the ones to use but with one caution: Both the quinolones and the tetracyclines have anti-inflammatory properties, they block inflammatory cytokines, and they can have analgesic effects independent of their antimicrobial effects.

At the 2016 AUA annual meeting, there was a course on surgical management of chronic orchialgia, including microscopic denervation of the spermatic cord, cremasteric release, vasectomy reversals, selective epididymectomy, varicocele repair, and orchiectomy. When do you think surgery is reasonable, and how do you choose which of these procedures to try?

We really like to allow at least 6 months of conservative measures a chance to fail. Again, history will drive much of this. For the rare man whose every symptom is confined to the epididymis, particularly if it’s abnormal on imaging and its only physical finding is tenderness of the epididymis, then an epididymectomy may be considered. I don’t do it commonly.

I believe the ultimate test for the feasibility of a surgical approach is to do a diagnostic cord block in the office where you palpate the cord, inject 10-20 ccs of bupivacaine, perhaps with some lidocaine as well, and have the patient assess their response. If they have complete resolution of their pain, at least temporarily, that is an indicator that the pain generator is coming from the spermatic cord or lower, that we’re probably dealing with signals from the genital branch of the genitofemoral nerve.

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If there is no relief, it would mean that local therapy by a urologist is probably not going to help and then we refer to a pain management specialist who may be better suited to treat pain at a higher level. If the cord block works and the patient has had a vasectomy, we discuss the potential for vasectomy reversal. Of course, that does not work in every case for pain relief, and it does render the patient fertile again. So it has those downsides, and it can be an expensive procedure. While many insurance companies will cover it for this reason, some may not and some people may have to pay out of pocket for it.

That leaves microscopic spermatic cord denervation. We do offer it to patients who have failed conservative measures and who have had a positive test from the block. In my clinic, we refer to the best responders as having a “positive laughing sign.” If, after doing the block, the patient starts laughing on the exam table because he feels so good because he may have been in pain for 5 years and this is the first time he is without pain, that to me, unscientifically, is the best predictor of improvement.

I do a standard microsurgical denervation as I learned from Dr. Larry Levine through his presentation at the AUA a few years ago. I had not, since my residency, ever done inguinal varicocele surgery but I do have experience doing microsurgery and I believe my learning curve was actually quite short. I think anyone who is comfortable doing a varicocele repair with microscopic magnification can learn this operation very simply.

I think you have to take great caution in offering orchiectomy. The failure rates are anywhere from 40% to 80%, and often patients may develop pain in the contralateral testicle following the procedure. I certainly know patients who have gone onto it; I have not yet in my practice had to do it.

Next: "Spousal Revenge Syndrome"

Please discuss your recent paper describing the potential role of psychological factors following extramarital sexual encounters (“Spousal Revenge Syndrome”) in the pathophysiology of CP/CPPS (Can J Urol 2016; 23:8176-8).

I didn’t come up with this idea, but I was surprised that I couldn’t find it in Medline. This is a cohort of men who have had some type of sexual encounter outside of either marriage or a committed relationship. Very often, the sexual encounter is one that would have a very low chance of actually infecting them; examples include genital stimulation at a strip club or oral sex while wearing a condom.

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They often then develop symptoms of a sexually transmitted disease. Sometimes, they may initially have one that gets treated and then the discharge goes away. But invariably, their pain continues. They have no response to antibiotics and all sexually transmitted infection testing is negative, and they are convinced that they have this condition.

When we have seen these patients in clinic, 100% in our experience have pelvic floor spasm. This is a reaction to guilt. It’s a pelvic floor reflex that sexual counselors say is commonly seen after sexual abuse. If the man is willing to accept this diagnosis and seek counseling and pelvic floor physical therapy, we have seen complete resolution of symptoms.

On the other hand, men who refuse to accept this therapy never get better in my experience. They go onto the next 20 infectious disease doctors and urologists. Very interesting to me is when the paper came out, one of my female urology colleagues, Dr. Courtenay Moore, told me that she has a cohort of women who developed similar symptoms after their husbands admit to infidelity, so this type of sexual pain is certainly not confined just to the men.

I think it’s really important to disseminate this. Why? Because many urologists don’t know about it and certainly no infectious disease doctor I’ve ever met has heard of this. So when patients go to see the next internist, they just get the whole other battery of cultures and genotyping for any microorganism.

I think all urologists have seen it, but no one has ever put it together like you did. It’s such a real syndrome and I think there will be further papers coming out on it now that it’s out there.

Recently, my fellow who has been working with me in the clinic came out of a room just shaking his head and saying: “I didn’t believe it, but there’s another one.” It’s just cookie-cutter.

Is there anything else that you’d like to add?

Yes. I think the hesitation that many urologists have in seeing these patients and investigating them stems from a fear of being stuck with men for whom they have to write chronic narcotic prescriptions and that they’re stuck managing their pain for life. I can tell you honestly, I have never written a narcotic prescription for chronic non-postoperative pain. These men should be managed by a pain specialist. Mismanagement of chronic narcotics can be fatal and should not be done by those of us in urology who are undertrained.

This is made very clear to all of my patients: If the cord block doesn’t help you, you do not need a urologist, you need a pain management specialist. If the surgery doesn’t help you, you need to see a pain management specialist. You have to explain this to the patient ahead of time. I think most patient frustration comes from their perception that the physician doesn’t really know what they’re doing and is just trying things at random. When you present a rational algorithm, the patients are very accepting. Building in expectations at the initial meeting goes a long way.

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