How to manage a 65-year-old male with chronic scrotal pain and prostatomegaly?

Management of Chronic Scrotal Pain in a 65-Year-Old Male with Prostatomegaly

For a 65-year-old male with bilateral chronic scrotal pain and prostatomegaly, a comprehensive urological evaluation is necessary, focusing on both the scrotal pain and the enlarged prostate as potential contributing factors.

Initial Assessment

• Perform a thorough physical examination of the scrotum, focusing on areas of tenderness, masses, or abnormalities that could explain the pain 1
• Conduct a digital rectal examination to further evaluate the prostatomegaly and check for tenderness or nodules 1
• Order urinalysis and urine culture to rule out infection, despite the current negative urine MCS 1, 2
• Consider a scrotal ultrasound examination to identify potential causes of pain such as varicocele, hydrocele, epididymal cysts, or testicular pathology 1

Differential Diagnosis

• Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) with referred scrotal pain 3
• Chronic epididymitis, particularly given the history of multiple sexual partners 1
• Primary scrotal content pain without identifiable cause 4
• Prostatic enlargement causing referred pain or vascular congestion 1
• Sexually transmitted infections, especially considering multiple sexual partners 1

Management Plan

First-line Treatment

• Begin treatment with an alpha-blocker such as tamsulosin 0.4 mg once daily for 2-4 weeks to address both the prostatomegaly and potentially related scrotal pain 5
• Advise the patient to take tamsulosin approximately 30 minutes after the same meal each day 5
• Recommend warm sitz baths and scrotal support to provide symptomatic relief 1
• Consider non-steroidal anti-inflammatory drugs (NSAIDs) for pain management if not contraindicated 1

Sexual Health Considerations

• Given the history of multiple sexual partners, perform nucleic acid amplification tests (NAATs) for Chlamydia trachomatis and Neisseria gonorrhoeae 1
• If STI testing is positive, treat with appropriate antibiotics according to guidelines 1
• Counsel on safe sexual practices to prevent recurrent infections 1

Follow-up and Monitoring

• Schedule a follow-up visit after 2-4 weeks to assess response to alpha-blocker therapy 5
• If symptoms persist despite alpha-blocker therapy, consider increasing tamsulosin to 0.8 mg once daily 5
• For persistent pain despite medical management, consider referral to a urologist with expertise in chronic scrotal pain 4, 6

Second-line Options

• For patients with persistent pain despite first-line treatments, consider:
  • Specialized pain management consultation 6
  • Pelvic floor physical therapy if pelvic floor dysfunction is suspected 3
  • In refractory cases, microsurgical spermatic cord denervation may be considered as a definitive treatment option 4, 6

Important Considerations

• Chronic scrotal pain can significantly impact quality of life and mental health; assess for depression and anxiety 7
• Post-ejaculatory pain may be a significant component of CP/CPPS and should be specifically asked about 7
• Patients with persistent ejaculatory pain tend to have more severe symptoms and poorer quality of life 7
• Inflammation in the male genital tract can affect fertility, which may be relevant if the patient has reproductive concerns 8

Red Flags Requiring Urgent Evaluation

• Development of acute severe pain or swelling 1
• Fever or signs of systemic infection 1
• Development of a testicular mass 1
• Failure to respond to appropriate therapy within 4-6 weeks 1, 6