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

== Diagnosis and Evaluation ==

* See [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994986/figure/f1-cuaj-6-161/ Figure 1] from Original Report

=== UrologySchool.com Summary ===

* '''<span style="color:#ff0000">Mandatory (1):'''
** '''<span style="color:#ff0000">History and Physical Exam'''

* '''<span style="color:#ff0000">Optional'''
** '''<span style="color:#ff0000">Labs (3):'''
*** '''<span style="color:#ff0000">Urinalysis +/- culture''' 
*** '''<span style="color:#ff0000">Sexually transmitted infection screen'''
*** '''<span style="color:#ff0000">Semen analysis'''
** '''<span style="color:#ff0000">Imaging (1):'''
*** '''<span style="color:#ff0000">Scrotal ultrasound'''
** '''<span style="color:#ff0000">Other (3):'''
*** '''<span style="color:#ff0000">Questionnaire'''
*** '''<span style="color:#ff0000">Spermatic cord block'''
*** '''<span style="color:#ff0000">Psychological evaluation'''

==== Mandatory ====

===== History and Physical Exam =====
* '''<span style="color:#ff0000">History'''
** Characterize pain (onset, location, quality, severity, referral, psychosocial impact, aggravating/alleviating factors)
** Urinary, bowel, and sexual function
** Potential risk factors for infectious causes of scrotal pain, such as epididymo-orchitis
** Potential reversible causes for scrotal pain
** PMHx and PSHx, including any previous scrotal, inguinal, abdominal, or pelvic surgeries
** Prior evaluations/interventions for the presenting pain, as well as whether any prior treatment has brought relief
** History of psychological, physical, or sexual abuse
*** Males with a history of abuse are at increased risk of CP/CPPS
* '''<span style="color:#ff0000">Physical exam (4)'''
*# '''<span style="color:#ff0000">Scrotum'''
*#*'''Patient should be examined in both standing and supine position'''
*#*Examination should begin on the non-painful or less painful side
*#* Testis, epididymis, vas should be carefully palpated for any anatomic abnormalities and to localize the source of the scrotal pain
*# '''<span style="color:#ff0000">Inguinal area''' 
*#*should be carefully inspected for surgical scars, hernias, or areas of tenderness. Care should also be taken to identify '''tenderness in the region of the adductor insertion''', which is often found in men presenting for investigation of CSP.
*# '''<span style="color:#ff0000">Digital Rectal Exam'''
*#*'''<span style="color:#ff0000">Essential</span>''' to assess for any abnormalities of the prostate, as well as hypertonicity or point tenderness of the pelvic floor structures.
*# '''<span style="color:#ff0000">Screening neurological examination of the lower limbs and genitals''' 
*#*Often required to assess for sensory deficits and radicular syndromes.

==== Optional ====

===== Labs =====
* '''Urinalysis +/- culture''' '''(select patients)'''
** '''Should be ordered in the setting of lower urinary tract symptoms, hematuria''', '''or any suspicion of infection''' '''since''' '''CSP may occur in the setting of a symptomatic UTI, STI, or prostatitis'''
* '''Sexually transmitted infection screen (select patients)'''
** If the patient is at a high risk for sexually transmitted infections or has complaints of urethral discharge, urethral symptoms, or penile pain, then a urethral swab or urine for nucleic acid amplification for Neisseria gonorrhea and Chlamydia trachomatis (G+C) should be ordered.
* '''Semen analysis (select patients)'''
** '''May be considered in young patients with CSP and non-proven fertility, especially if an infectious etiology is suspected, such as a history of STI or epididymo-orchitis.'''

===== Imaging =====
* '''Scrotal ultrasound (select patients)'''
** '''Should be performed if there is a palpable abnormality (such as a mass) in the scrotum or where pain or patient body habitus precludes a proper physical examination'''
** Although scrotal US is a safe and relatively inexpensive investigation often ordered in the CSP population, its clinical utility is limited in the setting of a normal scrotal examination and it may detect clinically insignificant findings, potentially leading to further investigations or unnecessary procedures.

===== Other =====
* '''Questionnaire'''
** '''Chronic Epididymitis Symptom Index (CESI)''' 
***Measures the severity, frequency, and impact of chronic epididymitis; can serve as a useful tool for baseline evaluation, as well as follow-up
* '''Spermatic cord block'''
** '''Can serve be both diagnostic and therapeutic''' in patients with idiopathic CSP
** '''Response will help differentiate local scrotal pain from referred pain'''
* '''Psychological evaluation (select patients)'''
** '''Referral to a mental health specialist is indicated if:'''
**# Patient endorses significant psychiatric response to ongoing pain
**# Pain affects non-medical aspects of life (relationships, employment, legal issues)
**# Pain is accompanied by anxiety, depression, or significant mental distress