para>Malingering and secondary gain are issues to consider, as is a history of sexual abuse (4,5)[C].
Physical Exam
- General physical exam
- Focused exam
- Palpation of scrotal components supine and standing
- Rectal and prostate exam
Alert
Evidence of mass warrants ultrasound (3)[B].
Differential Diagnosis
- Urinary tract infection
- Epididymitis
- Prostatitis
- Urolithiasis
- Testicular torsion
- Testicular tumor
- Hernia
- Hydrocele or varicocele
- Traumatic injury
- Radicular or referred pain
Diagnostic Tests & Interpretation
Initial Tests (lab, imaging)
- Urinalysis (1,3,5)[B]
- Urine culture, if indicated (3,5)[B]
- Prostatic fluid and/or semen culture, if indicated (5)[C]
- STD testing as indicated (3)[B]
- Scrotal ultrasound (3,5)[B]
Follow-up tests & special considerations
- CT, if concern for ureteral calculi (3)[B]
- MRI of lumbosacral spine, if suspicion of radiculitis (5)[C]
Diagnostic Procedures/Other
- Spermatic cord block with 1% lidocaine (6)[C]
Test Interpretation
- Relief from spermatic cord block indicates testes etiology (6)[B].
- Treat positive results for any infection.
- Refer to specialists per diagnostic test results.
Treatment
General Measures
Avoid aggravating activities.
Medication
First Line
- NSAIDs (5)[C]
- Antibiotics only with signs of infection (5)[C]
- Doxycycline or fluoroquinolone preferred for up to 4 weeks (5)[C]
Alert
Empirical use of antibiotics not supported by evidence; use only with signs of infection (1)[B].
Second Line
- Gabapentin 300 mg daily, titrating up to as much as 3,600 mg daily (5)[C]
- Amitriptyline 10 " 25 mg nightly (5)[C]
- Nortriptyline 10 " 150 mg daily (5)[C] (although doses above 75 mg unlikely to be beneficial)
- Amitriptyline and nortriptyline not effective for postvasectomy pain (5)[C]
- Tramadol for moderate persistent pain (3)[A]
- Opioids only for severe pain, rarely indicated (3)[A]
Issues for Referral
- Surgical
- Hydrocele
- Varicocele
- Testicular or epididymal mass
- Pain clinic for refractory pain
- Transcutaneous electrical nerve stimulation (TENS)
- Spermatic cord block
- Pelvic plexus local anesthetic
- Psychiatric or psychological counseling
- Vascular surgeon
- Orthopedic surgeon
- Gastroenterologist
Surgery/Other Procedures
- Microdenervation of spermatic cord (1,5)[B]
- Pulsed radiofrequency treatment denervation of spermatic cord (5)[B]
- Reversal of vasectomy (1,5)[B]
- Orchiectomy (1,5)[B]
Complementary & Alternative Therapies
Pelvic floor physiotherapy (1)[B]
Inpatient Considerations
Admission Criteria/Initial Stabilization
- Severe refractory pain
- Pain management
- Indicated lab and imaging tests
IV Fluids
Per presentation
Nursing
Routine
Discharge Criteria
- Controlled pain
- Outpatient follow-up
Ongoing Care
Follow-up Recommendations
Patient Monitoring
- Evaluate response to treatment.
- Modify treatment accordingly.
- Refer to specialists as indicated.
Diet
No restrictions
Patient Education
Reassurance to relieve patient anxiety, especially in regard to testicular cancer
Prognosis
- Orchiectomy success rates vary from 20 to 70% (5).
- Should be considered last resort, given that up to 80% of postorchiectomy patients may still have orchialgia
- Epididymectomy success from 10 to 80% (5)
- Limited studies indicate 71 " 89% pain resolution with microdenervation of spermatic cord (5).
- Key prognostic criterion is positive response to spermatic cord block.
- Vasectomy reversal up to 80%, effective albeit at the cost of undoing sterilization (5)
Complications
Surgical interventions include risk of hematoma, hydrocele, testicular atrophy, and infection.
References
1.Keoghane SR, Sullivan ME. Investigating and managing chronic scrotal pain. BMJ. 2010;341:c6716.
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2.Quallich SA, Arslanian-Engoren C. Chronic unexplained orchialgia: a concept analysis. J Adv Nurs. 2014;70(8):1717 " 1726.
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3.Kumar P, Mehta V, Nargund VH. Clinical management of chronic testicular pain. Urol Int. 2010;84(2):124 " 131.
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4.Quallich SA, Arslanian-Engoren C. Chronic testicular pain in adult men: an integrative literature review. Am J Mens Health. 2013;7(5):402 " 413.
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5.Levine L. Chronic orchialgia: evaluation and discussion of treatment options. Ther Adv Urol. 2010;2(5 " 06):209 " 214.
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6.Masarani M, Cox R. The aetiology, pathophysiology and management of chronic orchialgia. BJU Int. 2003;91(5):435 " 437.
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Codes
ICD09
- 608.9 Unspecified disorder of male genital organs
- 604.90 Orchitis and epididymitis, unspecified
- 601.9 Prostatitis, unspecified
- 959.14 Other injury of external genitals
ICD10
- N50.8 Other specified disorders of male genital organs
- N45.2 Orchitis
- N41.9 Inflammatory disease of prostate, unspecified
- N45.1 Epididymitis
- S39.94XA Unspecified injury of external genitals, initial encounter
SNOMED
- 63901009 Pain in testicle (finding)
- 274718005 Orchitis (disorder)
- 9713002 Prostatitis (disorder)
- 31070006 Epididymitis (disorder)
- 442236004 Pain in testicle as late effect of injury to testicle (disorder)
Clinical Pearls
- Empirical antibiotics not supported by evidence
- Scrotal ultrasound required if evidence of mass
- Orchiectomy treatment of last resort