Genital pain: algorithm for management

Abstract

Chronic testicular pain although becoming very common in our patient population poses a challenge to the physician, the patient and his family. The pathogenesis of chronic orchialgia (CO) is not well understood. The objective of this paper is to review the current literature on chronic testicular pain and its management and to propose an algorithm for its treatment. Abstracts, original papers and review articles were reviewed during a literature search using words such as testicular pain, CO, and microsurgical anatomy of spermatic cord. Chronic scrotal content pain (CSP) is a difficult condition to treat and could be idiopathic or secondary. Conservative therapy is the first line of treatment attempted to allow the patient to return to his routine activities. When conservative treatment fails, patients can now turn toward surgical options such as microsurgical denervation of the spermatic cord (MDSC) which has a success rate published in the 60–85% range and/or minimally invasive therapies such as microcryoablation of the spermatic cord, Botox or Amniofix injection. There is an increase in referrals for CO. The true pathogenesis is still unclear and the road to complete recovery is unsure for certain patients. This paper proposes an algorithm for the management of patients suffering with CO.

A Review of the Management of Chronic Scrotal Pain

“…Microsurgical denervation of the spermatic cord (MDSC) is a minimally invasive surgical procedure used to manage CSP after the failure of conservative treatments [ 36 , 37 ]. Multiple retrospective studies have examined the use of MDSC for CSP.…”

“…An increasingly used surgical treatment is Botox injection [ 34 , 37 ] because the botulinum-A toxin has been shown to modulate the release of neuropeptides (substance P and calcitonin gene-related peptide) that inhibit neurogenic inflammation and chronic pain [ 35 ]. However, a randomised, double-blind, controlled trial by Dockray et al found no superiority of onabotulinumtoxinA plus a local anaesthetic compared to a local anaesthetic alone for the control of SCP pain.…”

“…Other, rarely mentioned, surgical treatments for CSP that need more research include laparoscopic denervation [ 1 , 2 ], robotic denervation [ 46 ], resection of the genitofemoral nerve [ 2 ], sperm granuloma resection [ 16 ], AmnioFix® injection [ 36 , 37 ], spinal cord stimulation [ 36 ], scrotoscopy using the novel autoclave [ 47 ] and microsurgical sub-inguinal cremaster muscle release (MSCMR), which has been shown to be an effective option that has a relatively low rate of complications in cases of chronic orchialgia that has been clearly identified as secondary to testicular retraction due to a hyperactive cremaster muscle reflex and in which all other aetiologies of orchialgia have been ruled out [ 48 ]. Table 6 analyses vasectomy reversal, epididymectomy and orchidectomy in the last five years’ publications.…”

<p>Management of Chronic Orchialgia: Challenges and Solutions – The Current Standard of Care</p>

“…Calixte et al 66 performed a retrospective review of 44 patients with failed MDSC who underwent Scrotox from July 2013–2016. One hundred units of Botox diluted in 10cc of saline were injected medial and lateral to the spermatic cord at the level of the external inguinal ring.…”

“…Calixte et al 66 performed a retrospective review of 82 patients who underwent TRAAD from June 2009 to April 2019. Selection criteria were as follows: chronic groin pain (>3 months), failed standard pain management treatments (including MDSC), patients who have persistent pain after orchiectomy and negative urologic workup.…”