Editing CUA: Chronic Scrotal Pain (2018)

'''See [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994986/ Original Report]'''

== Background ==

* '''<span style="color:#ff0000">Definition of chronic scrotal pain (CSP):'''
** '''<span style="color:#ff0000">Intermittent or constant, unilateral or bilateral pain localized to the scrotal structures'''
** '''<span style="color:#ff0000">≥3 months in duration'''
** '''<span style="color:#ff0000">that significantly interferes with daily activities and prompts medical attention'''
* Scrotal pain may arise not only from the testicles, but can involve adjacent paratesticular structures, such as the epididymis and vas deferens, or pain may be referred from conditions involving the spermatic cord or the retroperitoneum. Therefore, the broader term chronic scrotal pain is more descriptive than testicular pain when referring to this condition.
* '''CSP is often debilitating and associated with:'''
** '''Depression'''
** '''Anxiety'''
** '''Sexual dysfunction'''
** '''Decreased quality of life'''

== Epidemiology ==

* Prevalence ≈1–4% in Canada

== Anatomy ==

* See [[Testicle|Testicle Anatomy Chapter Notes]]
* '''Testicular innervation'''
** '''Sensory innervation of the scrotum and scrotal contents occurs via 2 somatic nerves:'''
**# '''Genital branch of the genitofemoral nerve (L1–L2)'''
**# '''Ilioinguinal nerve (L1)'''
** Autonomic innervation
*** Of the testis is from the presacral ganglia of T10–T12
*** Of the epididymis and vas deferens is from T10–L1

== Pathophysiology ==

* Poorly understood
* '''<span style="color:#ff0000">Potential causes (7):'''
*# '''<span style="color:#ff0000">Vasectomy (most common identifiable cause,''' 21%''')'''
*# '''<span style="color:#ff0000">Trauma''' (12%)
*# '''<span style="color:#ff0000">Infection''' (11%)
*# '''<span style="color:#ff0000">Hernia repair''' (5%)
*# '''<span style="color:#ff0000">Epididymal cyst''' (2%)
*# '''<span style="color:#ff0000">Other identified causes (Hydrocelectomy, TURP, orchiectomy, donor nephrectomy) (6%)'''
*# '''<span style="color:#ff0000">Unknown'''
*#* '''<span style="color:#ff0000">Up to 50% of patients presenting with chronic scrotal pain will not have an identifiable etiology</span>''', making medical or surgical management difficult.
* '''Common causes of referred pain to the scrotal contents include mid-ureteral stones and radiculitis''' from degeneration of the thoracic and lumbar spine.
* '''Structures outside of the scrotum (tendons, muscles, ligaments, hernias) may bring the patient for an assessment of his “CSP”''' when, in fact, the pain is due to a non-scrotal source in close proximity to the groin.
** '''Other causes of referred scrotal pain include nerve entrapment by either an indirect inguinal hernia, scarring from prior inguinal surgery, or tendonitis of the insertion of the inguinal ligament into the pubic tubercle.'''

== 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

== 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)

== References ==

* [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994986/ Jarvi, Keith A., et al. "Canadian Urological Association best practice report on chronic scrotal pain." ''Canadian Urological Association Journal'' 12.6 (2018): 161.]