Editing CUA: Chronic Scrotal Pain (2018) (section)

== Management ==

* Natural history remains poorly studied
* See [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994986/figure/f2-cuaj-6-161/ Figure 2] from Original Report
* '''<span style="color:#ff0000">First-line (3):'''
*# '''<span style="color:#ff0000">Lifestyle changes'''
*#* '''Modification of aggravating activities, scrotal support, and heat or cold therapies'''
*# '''<span style="color:#ff0000">Physical therapy and acupuncture'''
*#* May improve CSP related to pelvic floor muscle dysfunction or referred pain from radiculopathies
*# '''<span style="color:#ff0000">Psychological counselling'''
*#* May help treat maladaptive self-harming behaviours, prevent catastrophic thinking, and potentially decrease pain-related physical limitations
* '''<span style="color:#ff0000">Second-line (if conservative strategies fail)'''
** '''<span style="color:#ff0000">Medical management'''
*** See [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994986/table/t2-cuaj-6-161/ Table 2] from Original Guideline
*** '''NSAIDs x 4 weeks'''
*** '''If infectious epididymitis suspected (tenderness localizable to epididymis), consider 4-week trial of empiric antibiotics,''' with or without NSAIDs
*** '''In patients with identified neuropathic pain, consider a 4-week trial of gabapentin or nortriptyline.'''
**** The lowest recommended dose should be initially prescribed, with subsequent dose increases titrated to clinical benefit, while monitoring for adverse events.
**** If the initial selected medication (i.e., gabapentin) is not effective, then an alternative medication (i.e., nortriptyline) should be considered
**'''If the oral medications above are unsuccessful, consider nerve blockade''' as a therapeutic measure.
***'''Nerve block should be considered prior to any surgical management, as it may predict intervention success.'''
***Longer-term nerve blockade modalities are still considered experimental, but early results are promising

* '''<span style="color:#ff0000">Third line: surgical management'''
** See [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994986/table/t3-cuaj-6-161/ Table 3] from Original Guideline
** '''The choice of initial surgical approach should be directed by the likely etiology of pain.'''
*# '''Vasectomy reversal in patients with post-vasectomy syndrome'''
*#* '''Can result in complete pain resolution rates ranging from 50–100%, lower rates with epididymectomy (10–90%).''' For epididymectomy, it must be made clear to the patient that this procedure will make reconstruction of the reproductive tract impossible, possibly impacting future fertility.
*# '''Varicocelectomy in CSP patients with associated varicocele'''
*#* Up to 15% of the male population will have a varicocele, only ≈10% will have associated CSP.
*#* In select patients with CSP associated with varicocele, varicocelectomy has 80–100% success rate
*# '''Microsurgical denervation of the spermatic cord''' (MDSC)
*#* '''Purpose is to transect the ilioinguinal nerve and all the nerves of the spermatic cord''' while preserving the testicular artery and the lymphatics, thus ablating the afferent neural pathways that may contribute to CSP
*#* Has shown promise for idiopathic CSP, as well as post-vasectomy syndrome, with success rates ranging from 71–95%; should only be performed in dedicated centres with expertise.
*#* '''A diagnostic spermatic cord block is recommended prior to MDSC, as this may predict pain resolution success'''
*# '''Orchiectomy remains a surgical option in patients with pain refractory to all other interventions and should only be performed with an inguinal approach''' Success rates of inguinal orchiectomy range from 20–75%
*# '''Other options: onabotulinumtoxin A and pulsed radiofrequency denervation''' (shown in table but not further described in guidelines)