madman
Super Moderator
Introduction: Chronic scrotal pain (CSP) can be a debilitating condition for patients and is often difficult to characterize.
Methods: A review of the literature was performed using Embase, Cochrane and Medline databases in the period 1.January 2010 to 1.January 2021. We found 132 articles, and the authors screened abstract and references. Thirty-seven articles are included after removing duplicates.
Results: This review presents a variety of medical and surgical treatment options for CSP such as spermatic cord blocks (36–80% success rate), microsurgical denervation of the spermatic cord (76–100% success rates), Botox (56% success rate), targeted ilioinguinal and iliohypogastric peripheral nerve stimulation, and radical orchiectomy (55–75% success rate).
Conclusion: An overview of various treatment options, both non-surgical and surgical are provided, with the aim of establishing what may be the best treatment option for CSP.
Introduction
Scrotal pain is an umbrella term referring to a variety of problems causing discomfort or pain in the scrotum and may be caused by problems with the testis or other contents of the scrotum, including ductus deferens and epididymis. Chronic scrotal pain (CSP) is defined as constant or intermittent pain in the scrotum lasting for more than three months.1 CSP does not involve only testicular pain, as there may be pain involving the epididymis, vas deferens, or adjacent paratesticular structures.
*It is important that, on the first presentation, any scrotal pain, regardless of pain severity, is assessed and managed on the principles of an acute scrotum, due to time-sensitive conditions such as testicular torsion.1
The patient with acute scrotal pain is the urologist’s acute abdomen. Therefore, a thorough medical history and objective examination in order to make a tentative diagnosis (age, sexual medical history, and duration, severity, description of pain) are essential. Paraclinical examinations are sometimes necessary to support a clinical diagnosis. The balance is between the potential risk of exploring or have a conservative treatment. The typical acute are reviewed in the following: torsion testes or torsion appendices, epididymitis or other infection (epididymal-orchitis, Fournier's gangrene, inflammation (dermatitis, vasculitis, cellulitis), ischemia (incarcerated hernia), trauma, medication (Amiodarone) or be referred pain (appendicitis, aneurysm, ureteral stones) Some recognized causes of scrotal pain include spermatocele and varicocele, hydrocele, infected hydrocele, and testis tumor. 1
Another pathophysiological cause of CSP revolves around Wallerian degeneration in spermatic cord nerve fibers. This is evidenced by a paper published in 2013 that found that out of 56 men treated for CSP, 48 of them (84%) showed Wallerian degeneration in 1 or more spermatic cord nerve fibers, whilst in the controls, only 20% showed this degeneration.2
The nerve supply takes place mainly through the ilioinguinal nerve and the genitofemoral nerve, which can be helpful in diagnosing the disease in question, especially in cases with CSP. An overall treatment strategy for the evaluation of scrotal pain is shown in Figure 1.
CSP is not the same as scrotal pathology. It can be very frustrating for the patient to live with and challenging for clinicians to treat. In about 25–50% of patients, the pathophysiological cause is unknown and may be associated with depression, anxiety, or previous abuse. Conditions significantly affect the quality of life, e.g. sexuality, work possibilities, social relationships, and mental health.
In patients with CSP, it is often essential to repeat a thorough history, objective examination, urine analysis, and an ultrasound scan of the scrotum trying to determine the exact etiology, if possible.
Therefore, CSP can be a debilitating condition for patients. Due to the lack of clearly defined treatment guidelines, one may also experience a certain difficulty in treating this condition
However, CSP is often idiopathic and may be associated with vasectomy procedures. A systematic review showed that the overall average incidence of CSP due to vasectomy was 15%, with 24% in scalpel vasectomy and 7% in non-scalpel vasectomy. 3
Other, rarer causes include hernia repair and thoracolumbar junction syndrome.4,5 CSP may, possibly, be a misdiagnosis in for example those with chronic hip pain.6
*The aim is to describe possible treatment options, both surgical and non-surgical, and to specify a “gold standard” treatment.
*Assessment of CSP
*Non-Surgical Treatment Options
Physical Therapy
Medications
Psychotherapy
Muscle Relaxants
Spermatic Cord Block Series
Botulinum Toxin
*Surgical Treatment Options
Microsurgical Denervation of the Spermatic Cord
Peripheral Nerve Stimulation
Spinal Cord Stimulation
Cryo-Ablation
Hydro dissection
Orchiectomy
Future Direction
The constantly evolving literature of CSP has led to the increased knowledge of diagnosis and treatment, from oral medications to invasive treatments. This is shown by an extensive review published earlier this year. 29 With each study, we develop a more thorough, evidence-based algorithm to guide urologists in the treatment of CSP
Conclusion
In general, CSP is a poorly understood problem with a variety of causes and considerations, which still requires more research in the future.
There are useful non-surgical and surgical options for CSP that depend on the patient’s state, the severity of the complaint, and what options have already been tried.
We recommend for the individual patient when other etiologies are ruled out to use multidisciplinary treatment modalities including physical therapy and psychotherapy as useful tools for coping with this condition.
Methods: A review of the literature was performed using Embase, Cochrane and Medline databases in the period 1.January 2010 to 1.January 2021. We found 132 articles, and the authors screened abstract and references. Thirty-seven articles are included after removing duplicates.
Results: This review presents a variety of medical and surgical treatment options for CSP such as spermatic cord blocks (36–80% success rate), microsurgical denervation of the spermatic cord (76–100% success rates), Botox (56% success rate), targeted ilioinguinal and iliohypogastric peripheral nerve stimulation, and radical orchiectomy (55–75% success rate).
Conclusion: An overview of various treatment options, both non-surgical and surgical are provided, with the aim of establishing what may be the best treatment option for CSP.
Introduction
Scrotal pain is an umbrella term referring to a variety of problems causing discomfort or pain in the scrotum and may be caused by problems with the testis or other contents of the scrotum, including ductus deferens and epididymis. Chronic scrotal pain (CSP) is defined as constant or intermittent pain in the scrotum lasting for more than three months.1 CSP does not involve only testicular pain, as there may be pain involving the epididymis, vas deferens, or adjacent paratesticular structures.
*It is important that, on the first presentation, any scrotal pain, regardless of pain severity, is assessed and managed on the principles of an acute scrotum, due to time-sensitive conditions such as testicular torsion.1
The patient with acute scrotal pain is the urologist’s acute abdomen. Therefore, a thorough medical history and objective examination in order to make a tentative diagnosis (age, sexual medical history, and duration, severity, description of pain) are essential. Paraclinical examinations are sometimes necessary to support a clinical diagnosis. The balance is between the potential risk of exploring or have a conservative treatment. The typical acute are reviewed in the following: torsion testes or torsion appendices, epididymitis or other infection (epididymal-orchitis, Fournier's gangrene, inflammation (dermatitis, vasculitis, cellulitis), ischemia (incarcerated hernia), trauma, medication (Amiodarone) or be referred pain (appendicitis, aneurysm, ureteral stones) Some recognized causes of scrotal pain include spermatocele and varicocele, hydrocele, infected hydrocele, and testis tumor. 1
Another pathophysiological cause of CSP revolves around Wallerian degeneration in spermatic cord nerve fibers. This is evidenced by a paper published in 2013 that found that out of 56 men treated for CSP, 48 of them (84%) showed Wallerian degeneration in 1 or more spermatic cord nerve fibers, whilst in the controls, only 20% showed this degeneration.2
The nerve supply takes place mainly through the ilioinguinal nerve and the genitofemoral nerve, which can be helpful in diagnosing the disease in question, especially in cases with CSP. An overall treatment strategy for the evaluation of scrotal pain is shown in Figure 1.
CSP is not the same as scrotal pathology. It can be very frustrating for the patient to live with and challenging for clinicians to treat. In about 25–50% of patients, the pathophysiological cause is unknown and may be associated with depression, anxiety, or previous abuse. Conditions significantly affect the quality of life, e.g. sexuality, work possibilities, social relationships, and mental health.
In patients with CSP, it is often essential to repeat a thorough history, objective examination, urine analysis, and an ultrasound scan of the scrotum trying to determine the exact etiology, if possible.
Therefore, CSP can be a debilitating condition for patients. Due to the lack of clearly defined treatment guidelines, one may also experience a certain difficulty in treating this condition
However, CSP is often idiopathic and may be associated with vasectomy procedures. A systematic review showed that the overall average incidence of CSP due to vasectomy was 15%, with 24% in scalpel vasectomy and 7% in non-scalpel vasectomy. 3
Other, rarer causes include hernia repair and thoracolumbar junction syndrome.4,5 CSP may, possibly, be a misdiagnosis in for example those with chronic hip pain.6
*The aim is to describe possible treatment options, both surgical and non-surgical, and to specify a “gold standard” treatment.
*Assessment of CSP
*Non-Surgical Treatment Options
Physical Therapy
Medications
Psychotherapy
Muscle Relaxants
Spermatic Cord Block Series
Botulinum Toxin
*Surgical Treatment Options
Microsurgical Denervation of the Spermatic Cord
Peripheral Nerve Stimulation
Spinal Cord Stimulation
Cryo-Ablation
Hydro dissection
Orchiectomy
Future Direction
The constantly evolving literature of CSP has led to the increased knowledge of diagnosis and treatment, from oral medications to invasive treatments. This is shown by an extensive review published earlier this year. 29 With each study, we develop a more thorough, evidence-based algorithm to guide urologists in the treatment of CSP
Conclusion
In general, CSP is a poorly understood problem with a variety of causes and considerations, which still requires more research in the future.
There are useful non-surgical and surgical options for CSP that depend on the patient’s state, the severity of the complaint, and what options have already been tried.
We recommend for the individual patient when other etiologies are ruled out to use multidisciplinary treatment modalities including physical therapy and psychotherapy as useful tools for coping with this condition.
