What is the treatment for chronic orchalgia?

Treatment of Chronic Orchialgia

The treatment of chronic orchialgia should follow a stepwise approach, beginning with conservative measures and progressing to surgical interventions only when conservative therapies fail, with microsurgical denervation of the spermatic cord showing the highest success rates (77-100%) for refractory cases. 1

Definition and Epidemiology

• Chronic orchialgia is defined as chronic or intermittent scrotal pain lasting at least three months that significantly interferes with daily activities 2
• Affects up to 100,000 men per year in the USA 3
• Accounts for 2.5-4.8% of urologic clinic visits 2
• Most commonly presents in men in their mid to late 30s, though can occur at any age 2

Diagnostic Approach

• Identify potential underlying causes:

  • Epididymitis
  • Varicocele
  • Hydrocele
  • Epididymal cysts
  • Iatrogenic injury (post-vasectomy, hernia repair)
  • Referred pain (mid-ureteral stone, inguinal hernia, lower back disorders)
  • Nerve entrapment
  • Idiopathic (25-50% of cases) 2

• Diagnostic workup should include:

  • Thorough history and physical examination
  • Scrotal ultrasound
  • Consider psychological and psychosocial factors that may contribute to chronic pain
  • Invasive testing is not recommended in the initial work-up 2

Treatment Algorithm

First-Line: Conservative Management

1. Non-pharmacological approaches:

   • Physical therapy
   • Application of heat or cold over the affected area
   • Stress management techniques
   • Pelvic floor muscle relaxation 4

2. Pharmacological options:

   • NSAIDs - First-line medication therapy 5
   • Tricyclic antidepressants (e.g., amitriptyline) - Start at low doses (10mg) and titrate gradually if needed 4
   • Gabapentin/Pregabalin - For neuropathic pain components 4
   • Topical agents - Consider lidocaine patches or creams 4

Second-Line: Minimally Invasive Interventions

If conservative measures fail after 3-4 months:

1. Spermatic cord blocks - Using local anesthetic (1% lidocaine) and corticosteroids (methylprednisolone) 5

   • Can be both diagnostic and therapeutic
   • Positive response may predict success with surgical denervation

2. Ultrasound-guided interventions:

   • Peri-spermatic cord cryoablation (59-75% success rate) 1
   • Botox injection ("Scrotox") (56-72% success rate) 1

3. Transrectal blockade of nerves from the pelvic plexus under ultrasound guidance 5

Third-Line: Surgical Interventions

For patients with persistent pain despite conservative and minimally invasive treatments:

1. Microsurgical denervation of the spermatic cord (MDSC) - 77-100% success rate 1

   • Preferred surgical option due to high success rate and preservation of testicular function

2. Targeted surgical approaches:

   • Varicocelectomy (if varicocele present)
   • Epididymectomy (if pain localized to epididymis)
   • Vasectomy reversal (69-100% success rate in post-vasectomy pain) 1

3. Last resort options:

   • Orchiectomy (20-75% success rate) 1
   • Should only be considered after failure of all other treatment options

Psychological Considerations

• Psychological factors may contribute to or exacerbate chronic orchialgia 6
• Consider:
  • Pain catastrophizing assessment
  • Evaluation for depression and anxiety
  • Cognitive behavioral therapy
  • Mindfulness-based stress reduction 4

Important Caveats

• Success rates for conservative therapy are generally poor, necessitating progression to more invasive options for many patients 3
• Orchiectomy should be considered only as a last resort due to variable success rates and permanent loss of the testicle 1
• A multi-modal approach combining physical, pharmacological, and psychological interventions often yields the best results
• Patients should be counseled that treatment may require multiple approaches before achieving adequate pain relief