Chronic orchialgia: evaluation and discussion of treatment options

Virtually all practicing urologists will encounter patients with a complaint of chronic testicular pain. This can be a frustrating process for both patient and physician, as there is no clearly established effective treatment regimen, nor is there a recognized and accepted standard protocol for evaluation. Many of these patients will see multiple physicians during the course of their evaluation, further increasing their frustration and potentially straining the physician/patient relationship. The etiology of testicular pain is varied and is frequently idiopathic. Easily recognized and reversible causes include spermatocele, tumor, infection, varicocele, and torsion. Chronic orchialgia has been defined as at least 3 months of chronic or intermittent pain. Although the diagnosis of chronic orchialgia is frequently given to these patients, it should be recognized that fairly frequently the patient will not have just testicular pain, but may have pain involving the epididymis, vas deferens, or adjacent paratesticular structures. Therefore a more appropriate term would be chronic scrotal content pain. This article reviews the current understanding of chronic scrotal content pain, reviewing the etiology, evaluation, and then a systematic review of the published literature on treatment. It should be recognized that the majority of the published literature are cohort studies with limited numbers of patients, rarely placebo-controlled, and without a uniform standard evaluation. Microdenervation of the spermatic cord is emerging as a reasonable and effective outpatient surgical technique to resolve chronic scrotal content pain, and successful results appear to be predicted by a temporary but complete response to a spermatic cord block.