What are the treatment options for testicular pain?

Treatment Options for Testicular Pain

The treatment of testicular pain must be guided by its underlying cause, with immediate urological consultation required for suspected testicular torsion which is a surgical emergency requiring intervention within 6-8 hours to prevent permanent testicular damage. 1, 2

Diagnosis and Initial Evaluation

• Doppler ultrasound is the first-line imaging modality for evaluating acute testicular pain, allowing differentiation between the most common causes: epididymitis/epididymo-orchitis, testicular torsion, and torsion of testicular appendage 1, 3
• The three most common causes of acute testicular pain account for 85-90% of cases, with presentation patterns varying by age 3
• Testicular torsion presents with sudden-onset severe pain and negative Prehn sign (pain not relieved by elevation of testicle) 3, 2
• Epididymitis typically presents with more gradual onset of pain, positive Prehn sign, and increased blood flow on ultrasound 3

Treatment Based on Etiology

Acute Testicular Pain

1. Testicular Torsion

   • Requires immediate surgical exploration and detorsion within 6-8 hours of symptom onset 1, 2
   • Surgical intervention includes orchiopexy (fixation of the affected testicle) and preventive fixation of the contralateral testicle 2
   • Post-operative care includes bed rest, scrotal elevation, and analgesics 2

2. Epididymitis/Epididymo-orchitis

   • Antimicrobial therapy based on likely pathogens (age and sexual history dependent) 3
   • Supportive measures including scrotal elevation, rest, and anti-inflammatory medications 3
   • Follow-up ultrasound may be necessary if symptoms persist despite appropriate therapy 1

3. Torsion of Testicular Appendage

   • Conservative management with rest, scrotal support, and analgesics is typically sufficient 3
   • Surgical intervention may be considered if pain is severe or persistent 3

Chronic Testicular Pain (Orchialgia)

• Defined as testicular pain lasting at least 3 months, often with no identifiable cause 4

• Initial management should be conservative, including:

  • Non-steroidal anti-inflammatory drugs 5
  • Scrotal support 5
  • Physical therapy and pelvic floor exercises 4
  • Consideration of neuropathic pain medications (gabapentin, pregabalin) 5

• For pain associated with varicocele:

  • Varicocelectomy resolves approximately 80% of cases with testicular pain in carefully selected patients with clinically palpable varicocele 6
  • Microsurgical techniques have shown favorable outcomes with minimal complications 6

• For refractory chronic pain without identifiable cause:

  • Spermatic cord block can be both diagnostic and therapeutic 4
  • Microsurgical denervation of the spermatic cord has emerged as an effective surgical option for patients who respond temporarily to spermatic cord block 4, 7
  • Epididymectomy may be considered in cases where pain is localized to the epididymis 4
  • Orchiectomy is considered a last resort when all other treatments have failed 8, 5

Clinical Pearls and Pitfalls

• The time-critical nature of testicular torsion cannot be overemphasized; delay in treatment beyond 6-8 hours significantly increases the risk of testicular loss 1, 2
• Clinical presentations of the common causes of testicular pain can overlap, making accurate diagnosis challenging without appropriate imaging 3
• Psychological factors may contribute to chronic testicular pain, and addressing these aspects may be beneficial in management 8, 5
• In chronic testicular pain, setting realistic expectations is important as complete resolution is not always achievable 5
• Surgical interventions for chronic pain should not be undertaken lightly, as there is no guarantee of symptom resolution 5