Orchialgia

Orchialgia

Orchialgia, or testicular pain, can be a difficult clinical situation for the patient and clinician because of the unique significance the testicle has as part of the male psyche. This fact is crucial if the clinician is to evaluate and treat successfully patients with orchialgia. Acute orchialgia represents a medical emergency and may be the result of trauma, infection, or inflammation of the testes or torsion of the testes and spermatic cord. Chronic orchialgia is defined as testicular pain that is of more than 3 months’ duration and significantly interferes with the patient’s activities of daily living. Chronic orchialgia can be the result of pathological processes that are extrascrotal in origin (e.g., ureteral calculi, inguinal hernia, ilioinguinal or genitofemoral nerve entrapment), diseases of the lumbar spine and roots, or pathological processes that are intrascrotal in origin (e.g., chronic epididymitis, hydrocele, varicocele). The history of all patients with chronic orchialgia should include specific questioning regarding a history of sexual abuse.

What are the Symptoms of Orchialgia

Physical examination of patients with acute orchialgia is directed at identifying acute torsion of the testes and spermatic cord, which is a surgical emergency. Patients with acute orchitis secondary to infections, including sexually transmitted diseases, present with testes that are exquisitely tender to palpation. For patients with chronic orchialgia, the physical findings are often nonspecific, with the testicle mildly tender to palpation, unless specific pathological processes are present. Patients with chronic testicular pain secondary to varicocele present with a scrotum that feels like a “bag of worms.” Patients with chronic epididymitis present with tenderness that is localized to the epididymis. Testicular malignancy always should be considered in any patient presenting with orchialgia. Physical findings in this setting vary, but testicular enlargement is often an early finding.

As mentioned earlier, extrascrotal pathological processes also can manifest with the primary symptom of orchialgia. One of the most common causes of orchialgia of extrascrotal origin is ilioinguinal or genitofemoral neuralgia. Ilioinguinal neuralgia manifests as a sensory deficit in the inner thigh and scrotum in the distribution of the ilioinguinal nerve. Weakness of the anterior abdominal wall musculature may be present. Tinel sign may be elicited by tapping over the ilioinguinal nerve at the point it pierces the transverse abdominis muscle. A patient with ilioinguinal or genitofemoral neuralgia may assume a bent-forward novice skier’s position to eliminate pressure on the affected nerve.

How is Orchialgia diagnosed?

Ultrasound examination of the scrotal contents is indicated in all patients with orchialgia. Radionucleotide and Doppler studies are indicated if vascular compromise is suspected.

Transillumination of the scrotal contents also can help identify varicocele.

Electromyography helps distinguish ilioinguinal nerve entrapment from lumbar plexopathy, lumbar radiculopathy, and diabetic polyneuropathy.

Based on the patient’s clinical presentation, additional tests, including complete blood cell count, uric acid level, erythrocyte sedimentation rate, and antinuclear antibody testing, may be indicated. Magnetic resonance imaging (MRI) and computed tomography (CT) of the lumbar plexus and pelvis is indicated if tumor or hematoma is suspected.

Differential Diagnosis

Extrascrotal pathology, including inguinal hernia, ilioinguinal neuralgia, and lesions of the lumbar plexus, nerve roots, and spinal cord, can mimic the pain of orchialgia and must be included in the differential diagnosis, as can a variety of systemic diseases. Considerable intrapatient variability exists in the anatomy of the ilioinguinal and genitofemoral nerves, which can result in variation in patients’ clinical presentation. The ilioinguinal nerve is a branch of the L1 nerve root with contribution from T12 in some patients. The nerve follows a curvilinear course that takes it from its origin of the L1 and occasionally T12 somatic nerves to inside the concavity of the ilium. The ilioinguinal nerve continues anteriorly to perforate the transverse abdominis muscle at the level of the anterior superior iliac spine. The nerve may interconnect with the iliohypogastric nerve as it continues along its course medially and inferiorly, where it accompanies the spermatic cord through the inguinal ring and into the inguinal canal. The distribution of the sensory innervation of the ilioinguinal nerves varies among patients because considerable overlap may occur with the iliohypogastric nerve. In general, the ilioinguinal nerve provides sensory innervation to the upper portion of the skin of the inner thigh and the root of the penis and upper scrotum in men.

Causes of Chronic Orchialgia

From Heidelbaugh JJ. Academic men’s health: case studies in clinical practice: chronic orchialgia. J Men’s Health . 2009;6:220–225.

  • Diabetic neuropathy
  • Epididymal cyst/spermatocele
  • Epididymitis
    • Infectious (e.g., Chlamydia trachomatis Neisseria gonorrhoeae Ureaplasma urealyticum , coliform bacteria)
    • Noninfectious (e.g., reflux of urine)
  • Fournier gangrene
  • Henoch-Schönlein purpura
  • Hydrocele
  • Idiopathic swelling
  • Inguinal hernia
  • Interstitial cystitis
  • Nephrolithiasis in the mid-ureter
  • Orchitis (e.g., mumps)
  • Polyarteritis nodosa
  • Previous surgical interventions (e.g., vasectomy, herniorrhaphy, scrotal procedures)
  • Prostatitis
  • Psychogenic (e.g., history of sexual abuse, relationship stress)
  • Referred pain from abdomen or pelvis resulting from entrapment of genitofemoral or ilioinguinal nerve roots (T10–L1), with or without a history of surgery
  • Testicular torsion or torsion of the appendix testis (intermittent)
  • Testicular vasocongestion from sexual arousal without ejaculation
  • Trauma
  • Tumor (e.g., testicle, epididymis, spermatic cord)
  • Statin use
  • Varicocele
  • Vasectomy (postvasectomy pain syndrome)

Treatment

Many treatments have been advocated for orchialgia, with varying degrees of success. Initial treatment of the pain associated with orchialgia should include a combination of nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors and physical therapy. Local application of heat and cold may be beneficial. The use of supportive undergarments or an athletic supporter may provide symptomatic relief.

For patients who do not respond to these treatment modalities, injection of the spermatic cord or ilioinguinal and genitofemoral nerves with a local anesthetic and steroid may be a reasonable next step. If the symptoms of orchialgia persist, surgical exploration of the scrotal contents should be considered. Psychological evaluation and interventions should take place concurrently with the previously mentioned treatment modalities.

Treatment Options for Chronic Testicular Pain

From Granitsiotis P, Kirk D. Chronic testicular pain: an overview. Eur Urol . 2004;45:430–436.

  • Nonsurgical management
    • Antibiotics and nonsteroidal antiinflammatory drugs
    • Alpha-adrenergic antagonists
    • Tricyclic antidepressants, gabapentin, carbamazepine
    • Allopurinol
    • Transcutaneous electrical nerve stimulation
    • Pulsed radiofrequency
  • Minimally invasive treatment options
    • Needle aspiration or enucleation of cystic lesion that might be relevant to the site of pain
    • Local anesthetic infiltration of the spermatic cord with or without methylprednisolone
    • Local anesthetic infiltration of the pelvic plexus under transrectal ultrasound guidance
    • Direct intraprostatic injection of antibiotic and methylprednisolone
  • Surgical intervention
    • Denervation of the spermatic cord
    • Vasovasostomy or vasoepididymostomy in the postvasectomy pain syndrome
    • Orchiectomy

Complications

The major pitfalls in the care of a patient with orchialgia are fourfold: (1) the misdiagnosis of extrascrotal pathology responsible for the patient’s pain, (2) the failure to identify testicular malignancy, (3) the failure to identify vascular compromise or infectious causes of acute orchialgia, and (4) the failure to address the psychological issues surrounding the patient’s pain.

Clinical Pearls

The clinician should be aware that the relationship of the genitalia to the male psyche presents some unique challenges when treating patients suffering from orchialgia.

The behavioral and psychological issues must be addressed concurrently with the medical issues if treatment is to be successful.

The possibility for testicular malignancy is ever present and should be carefully sought in all patients with orchialgia.


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