What is the management approach for chronic orchalgia?

Management of Chronic Orchalgia

Begin with conservative medical management for 3-6 months before considering any surgical intervention, as most patients will achieve meaningful pain reduction without surgery. 1, 2

Initial Assessment and Diagnostic Workup

Conduct a biopsychosocial assessment that evaluates pain onset, duration, intensity, character, exacerbating/alleviating factors, past treatments, and the effect on physical and psychological function. 3

Key History Elements to Obtain:

• Duration and pattern of pain (chronic orchalgia is defined as intermittent or constant testicular pain >3 months) 4
• Prior scrotal surgeries (present in 8 of 9 patients in one series) 5
• Response to previous treatments including NSAIDs, antibiotics, and pain medications 5
• Impact on daily activities and quality of life using standardized tools like the Brief Pain Inventory (BPI) or 3-item PEG scale 3, 6
• Psychosocial factors including depression, anxiety, and coping strategies 3

Physical Examination and Testing:

• Complete scrotal examination to exclude organic pathology 4
• Scrotal ultrasound to rule out structural abnormalities, varicocele, hydrocele, or masses 4
• Assess for referred pain from inguinal hernia, hip pathology, or lumbar spine disease 1

Conservative Medical Management (First-Line Treatment)

Start with NSAIDs as initial pharmacotherapy for symptom control, as they provide partial pain relief in many patients. 4, 2

Pharmacologic Options:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) - first-line agent 4, 2
• Neuropathic pain medications (gabapentin, pregabalin) for nerve-related pain 2
• Tricyclic antidepressants (amitriptyline, nortriptyline) for chronic pain modulation 2
• Antibiotics only if infectious etiology suspected (trial in select cases) 5

Non-Pharmacologic Interventions:

• Patient education on pain neurophysiology and self-management strategies 3, 6
• Physical therapy focusing on pelvic floor dysfunction if present 6, 7
• Scrotal support and activity modification 1
• Psychological support including cognitive behavioral therapy for pain coping strategies 3

Interventional Procedures (Second-Line Treatment)

If conservative management fails after 3-6 months, proceed with diagnostic spermatic cord block using 1% lidocaine and methylprednisolone to predict response to surgical denervation. 5, 4

Minimally Invasive Options (in order of preference):

1. Targeted spermatic cord blocks (diagnostic and therapeutic)

   • Success rate: Provides temporary relief in most patients 5
   • Technique: Combination of 1% lidocaine and 40 mg methylprednisolone 4

2. Microsurgical denervation of the spermatic cord (MDSC)

   • Success rate: 77-100% - highest success rate among surgical options 1
   • Indicated when cord block provides temporary relief 5, 1
   • Preserves testicular function and avoids orchiectomy 5

3. Ultrasound-guided peri-spermatic cord cryoablation

   • Success rate: 59-75% 1
   • Less invasive alternative to open denervation 1, 8

4. Botulinum toxin (Scrotox) injection

   • Success rate: 56-72% 1
   • Novel treatment option with reasonable efficacy 8

5. Transrectal pelvic plexus blockade

   • Technique: 5 ml bupivacaine and methylprednisolone under ultrasound guidance 4
   • Consider when inguinal approaches fail 4

Surgical Management (Third-Line Treatment)

Reserve orchiectomy as a last resort only after all conservative and minimally invasive options have failed, as success rates are variable (20-75%) and the procedure is irreversible. 1, 4

Surgical Options by Indication:

• Varicocelectomy - if varicocele identified as pain source 8
• Vasectomy reversal - if post-vasectomy pain syndrome (success rate: 69-100%) 1
• Epididymectomy - if epididymal pathology identified 8
• Radical orchiectomy - last resort (success rate: 20-75%, with 3 of 4 patients achieving complete relief in one series) 1, 4

Monitoring and Follow-Up

Reassess pain intensity, functional status, and quality of life at regular intervals using the "Four A's" framework:

• Analgesia (pain relief achieved) 3
• Activities of daily living (functional improvement) 3
• Adverse effects (medication side effects) 3
• Aberrant behaviors (if opioids prescribed) 3

Schedule follow-up every 4-6 weeks during initial treatment phase, then every 3 months once stable. 3

Interdisciplinary Team Approach

Develop an interdisciplinary team including urology, pain management, physical therapy, and behavioral health for complex cases that fail initial conservative management. 3, 6

Common Pitfalls to Avoid

• Proceeding directly to orchiectomy without attempting less invasive options (orchiectomy has lower success rates than MDSC) 1, 4
• Failing to perform diagnostic cord block before surgical denervation (predicts surgical success) 5
• Overlooking psychosocial factors that contribute to pain chronicity and disability 3
• Not setting realistic expectations - complete pain elimination may not be achievable; focus on functional improvement and quality of life 3, 6