What should the assessment look like for a 45-year-old male with bilateral scrotal pain consistent with a high tone pelvic floor disorder, normal scrotal exam and ultrasound (US), and suspected spine, hip, or musculoskeletal (MSK) problem?

Assessment for Bilateral Scrotal Pain with High Tone Pelvic Floor Disorder

For a 45-year-old male with bilateral scrotal pain consistent with a high tone pelvic floor disorder and normal scrotal exam/ultrasound, the assessment should focus on a comprehensive musculoskeletal and neurological evaluation of the pelvic floor, spine, and hip regions to identify the underlying cause of pain.

Initial Diagnostic Evaluation

Scrotal Assessment (Already Completed)

• Normal scrotal examination
• Normal scrotal ultrasound (Duplex Doppler) - confirms absence of testicular pathology 1

Pelvic Floor Assessment

• Digital rectal examination (DRE): Critical for identifying pelvic floor muscle tension, tenderness, and trigger points 2

  • Assess for 360° pelvic floor muscle tone and tenderness
  • Evaluate for pain/tightness of levator ani and obturator internus muscles
  • Document specific trigger points that reproduce the scrotal pain

• Electromyography (EMG) of pelvic floor: To objectively measure pelvic floor muscle tone 3

  • Resting tone ≥3 μV indicates increased pelvic floor muscle tension
  • 88% of patients with chronic testicular pain show elevated resting tone (mean 6.7 μV) 3

Musculoskeletal Assessment

• Spine examination:

  • Assess lumbar spine range of motion and pain with movement
  • Check for radicular symptoms with straight leg raise
  • Evaluate for tenderness over lumbar facet joints and sacroiliac joints

• Hip examination:

  • Evaluate hip range of motion (flexion, extension, internal/external rotation)
  • FABER (Flexion, ABduction, External Rotation) test for hip pathology
  • Assess for iliopsoas and piriformis muscle tightness/tenderness

Neurological Assessment

• Sensory testing of lower abdomen, genitals, and lower extremities
• Motor testing of lower extremities
• Reflex testing of lower extremities
• Evaluation of pudendal nerve (Tinel's sign over pudendal nerve)

Functional Assessment

• Document symptoms in three domains that suggest pelvic floor dysfunction 3:
  1. Micturition (urinary hesitancy, frequency, urgency)
  2. Defecation (constipation, painful bowel movements)
  3. Sexual function (erectile dysfunction, painful ejaculation)
  • Note: 93% of patients with chronic testicular pain have at least one symptom in these domains 3

Psychological Assessment

• Evaluate for anxiety, depression, and catastrophizing behaviors
• Screen for history of trauma or abuse
• Assess impact of pain on quality of life and daily activities 4

Diagnostic Considerations

Differential Diagnosis

1. High tone pelvic floor disorder with referred scrotal pain
2. Lumbar radiculopathy affecting genitofemoral or ilioinguinal nerves
3. Hip pathology with referred pain
4. Pudendal neuralgia
5. Chronic pelvic pain syndrome
6. Myofascial pain syndrome

Common Pitfalls to Avoid

• Focusing only on genitourinary causes: The normal scrotal exam and ultrasound suggest looking beyond the scrotum for pain etiology
• Missing psychological components: Psychological factors often contribute to pelvic floor dysfunction 4
• Inadequate pelvic floor assessment: Digital rectal examination is essential for diagnosis of pelvic floor dysfunction 2
• Overlooking age considerations: Younger patients are more likely to have pelvic floor overactivity as a cause of testicular pain 3

Documentation Requirements

• Document all findings from physical examination
• Record specific trigger points that reproduce the patient's pain
• Note any functional limitations due to pain
• Document EMG findings if performed
• Record impact of pain on quality of life

By conducting this thorough assessment, you can identify the specific musculoskeletal or neurological factors contributing to the patient's bilateral scrotal pain and develop an appropriate treatment plan, which may include pelvic floor physical therapy as a first-line intervention 2.