II. History
- Characteristics of Testicular Pain
- Duration of pain (chronic defined as >3 months)
- Location of pain
- May be unilateral or bilateral
- Associated urologic symptoms
- Previous urologic surgery
- Vasectomy
- Genital Trauma
- Prior Hernia Repair
- Comorbid conditions
III. Causes
- Idiopathic in 25% of cases
- Intermittent Testicular Torsion
- Post-genitourinary surgery
- Sperm Granuloma (post-Vasectomy)
- Varicocele
- Testicular Cancer (painless in 60% of cases)
- Genitourinary infection (e.g. Sexually Transmitted Disease)
IV. Evaluation
- Assessment for Acute Testicular Pain is critical
- Assess for referred pain
- Nephrolithiasis in the mid-ureter (most common)
- Radiculopathy
- Genitofemoral and ilioinguinal nerves (T10-L1)
- Causes
- Inguinal Hernia
- Radiculitis
- Entrapment Neuropathy after Hernia Repair
- Sperm Granuloma
V. Signs
- Complete Male Genital Exam including Rectal Exam
VI. Labs
- Urinalysis
- Urine Culture
- Expressed Prostatic Secretions when indicated
- Gonorrhea and Chlamydia cultures
VII. Radiology
- Ultrasound with color flow doppler of Scrotum
- Consider Spiral CT Abdomen or intravenous pyelogram
VIII. Management
- Step 1
- NSAIDs
- Adjust Posture if due to radiculopathy
- Empiric Antibiotics for 2 weeks or more
- Cover Chlamydia and Ureaplasma
- Doxycycline
- Ciprofloxacin
- Step 2
- Spermatic Cord Block at pubic tubercle
- Bupivicaine (Marcaine) 0.25% 3 ml and
- Methylprednisolone 40 mg
- Inject no more often than once monthly
- Trascutaneous Electrical Nerve Stimulation (TENS)
- Spermatic Cord Block at pubic tubercle
- Step 3
- Multidisciplinary Pain Management
- Antidepressant medication
- Psychotherapy
- Step 4: Urologic Surgery
- Orchiectomy
- Surgical denervation Testes alon spermatic cord