What is the best course of action for intermittent left testicular pain that improves with scrotal elevation and has no apparent cause on ultrasound?

Chronic Scrotal Content Pain (Chronic Orchialgia)

Based on your 3-4 year history of intermittent left testicular pain that improves with scrotal elevation and negative ultrasound findings, you most likely have chronic scrotal content pain (chronic orchialgia), and should begin treatment with NSAIDs combined with scrotal support, followed by consideration of spermatic cord block if conservative measures fail, with referral to urology for possible microsurgical denervation if pain persists beyond 3 months of conservative therapy. 1, 2

Understanding Your Diagnosis

Your clinical presentation is classic for chronic scrotal content pain rather than an acute surgical emergency:

• Pain duration >3 months defines chronic orchialgia, which you clearly meet with 3-4 years of symptoms 2, 3
• Positive Prehn sign (pain relief with elevation) argues strongly against testicular torsion, where pain typically does NOT improve with elevation 4
• Normal ultrasound effectively rules out structural pathology including torsion, tumor, spermatocele, and significant varicocele 1
• Intermittent nature over years makes acute conditions like torsion or infection extremely unlikely 4, 1

Why This Isn't Testicular Torsion

While intermittent testicular torsion exists in patients with "bell-clapper" deformity (found in 82% of intermittent torsion cases), your presentation makes this unlikely because: 1

• Torsion pain is abrupt and severe, not chronic and intermittent over years 4
• Torsion requires intervention within 6-8 hours to prevent testicular loss 4
• Your positive Prehn sign (pain relief with elevation) is the opposite of torsion's negative Prehn sign 4
• Normal Doppler ultrasound has 96-100% sensitivity for detecting torsion 4, 5

Recommended Treatment Algorithm

Step 1: Conservative Management (First 3 Months)

• NSAIDs (ibuprofen or naproxen) combined with scrotal support/elevation should be your initial therapy 1, 6
• This addresses inflammation of paratesticular structures (epididymis, vas deferens) which is the most common cause in adults 5, 1
• Consider a trial of empiric antibiotics (fluoroquinolone or doxycycline for 2-4 weeks) even without confirmed infection, as this resolves pain in many cases 1, 6

Step 2: Diagnostic Spermatic Cord Block (If Step 1 Fails)

• A temporary but complete response to spermatic cord block predicts success with surgical denervation 2
• This helps differentiate true chronic scrotal content pain from referred pain or other causes 2, 3

Step 3: Surgical Intervention (If Conservative Measures Fail)

• Microsurgical denervation of the spermatic cord is emerging as the most effective surgical option, with success rates around 80% in carefully selected patients 1, 2, 3
• This should only be considered after at least 3 months of failed conservative therapy and a positive response to cord block 2, 3

Critical Next Steps

Immediate urology referral is warranted to evaluate for intermittent testicular torsion requiring bilateral prophylactic orchiopexy, even though your presentation makes this unlikely 1. The urologist can:

• Confirm the diagnosis of chronic orchialgia versus intermittent torsion
• Perform spermatic cord block for both diagnostic and therapeutic purposes 2
• Discuss surgical options if conservative management fails 1, 2

Important Caveats

• Psychological factors including depression commonly accompany chronic testicular pain and should be addressed 2, 3
• Avoid opiates until all other options are exhausted, including multidisciplinary pain management 6
• Orchiectomy (testicle removal) should be considered only as a last resort when all conservative and surgical denervation options have failed 3, 6
• The etiology is frequently idiopathic (unknown cause), which can be frustrating but doesn't preclude successful treatment 2, 3