Chronic scrotal pain
Chronic scrotal pain (CSP), also called chronic orchialgia or testicular pain syndrome, is one of the most challenging urological conditions to diagnose and treat.
Often, patients seek medical treatment for CSP from multiple specialists and undergo many diagnostic tests. In many cases, physicians are unable to determine the cause of the pain.
Not surprisingly, CSP can be extremely frustrating and debilitating. More than 50% of patients experience limited ability to work, decreased sexual activity and overall limitations to their daily activities. Patients with CSP also report feelings of depression, anxiety and isolation.
In 2018 the Canadian Urological Association released its best practice report on the management of chronic scrotal pain. Below is a summary.
Medical definition of chronic scrotal pain
CSP is defined as intermittent or constant pain in the scrotal structures (testicles and surrounding areas) for three months or longer. The pain significantly impacts daily activities and prompts the individual to seek medical help. It is estimated that CSP affects 1-4% of Canadian men.
Causes of chronic scrotal pain
Up to 50% of patients with CSP have no clear biological cause for their pain. Other patients experience CSP as a result of trauma, infection, a cyst, previous urological surgery or pain referred from other parts of the body, such as pain in the hip or groin muscles.
Diagnosing the problem
The process for diagnosing the cause of CSP involves multiple steps, which may include the following.
- Patient medical history
- Physical examination
- Infection screening
- Symptom questionnaire
- Ultrasound
- Spermatic cord block
- Psychological evaluation
- Testicular function screening
Treatment
Men with CSP are treated in a stepwise approach, starting with the least invasive options. Sometimes patients will be referred to other specialists for treatment (e.g. pain specialists or sports medicine specialists).
Conservative treatment and management of CSP may include scrotal support devices, heat or cold therapy, avoidance of physical activities that aggravate the condition, physiotherapy, active release therapy, acupuncture and psychological counselling.
Medication can be helpful for either pain management or treatment of infection, depending on the cause of the CSP. Common types of medications for CSP include the following.
- Non-steroidal anti-inflammatory drugs (NSAIDs), such as Ibuprofen or Naproxen
- Antibiotics
- Neuropathic pain medications, such as Gabapentin or Nortriptyline
For patients who don’t experience relief after conservative treatment measures or medications, a nerve block may be recommended. This involves injecting local anaesthetic into the spermatic cord to provide pain relief.
As a last resort, surgical management of pain may be considered. The type of surgery recommended will depend on the cause of the pain.
The Canadian Urological Association report describes CSP as “a common, complex, yet poorly understood condition that can be difficult to manage.” A combination of lifestyle changes, physical therapy, counselling and medication are helpful tools for many patients with CSP, providing coping strategies and empowerment.
Reference
Canadian Urological Association best practice report on chronic scrotal pain. Can Urol Assoc J 2018;12(6):161-72.