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Chronic Orchalgia
Diagnosis/Definition
- This guideline is intended for chronic scrotal pain. Acute scrotal pain may include torsion of the spermatic cord, testicle or its appendices and requires emergent specialty referral and therapeutic attention (usually surgery).
- Chronic scrotal pain is a common source of referral to the Urology Service. Although it is not life threatening, it may affect the patients quality of life. The prevalence of this symptom is unknown.
- To qualify as chronic scrotal pain, the pain has to have lasted for a minimum of six months . It can be unilateral or bilateral, and continuous or intermittent. It is not uncommon for examination to localize the site, and distinguish between testicular and epididymal pain.
The differential diagnosis is vast and includes the following:
- Testicular tumor (rarely painful)
- Hydrocele
- Spermatocele
- Varicocele cysts within the epididymis, tunica albuginea or spermatic cord.
The etiology of benign chronic orchalgia may be from any of the following:
- Prior vasectomy (post-vasectomy pain syndrome)
- Extragenital lesions including vertebral disease
- Ureteral stones
- Aortic or iliac aneurysm
- Constipation in children
- Hypermobility of the testis
- Entrapment of the pudendal/inguinal nerve (such as seen after hernia surgery), and
- Chronic pelvic pain of unknown cause.
Initial Diagnosis and Management
- A thorough physical examination should always include a careful genitourinary examination. Gentle palpation should be performed to identify each component of the scrotum. If possible, the site of pain usually can be localized.
- A digital rectal examination is mandatory.
- The integrity of the pelvis and spine should be examined.
- Standard laboratory evaluation must include the following: Urinalysis with culture, PSA in men over 50 years (or men over 40 years who are African American or have a family history for prostate cancer), urethral swab or urine PCR for gonorrhea and chlamydia infection.
- Scrotal ultrasonography must be performed as a baseline study to evaluate for lesions within the testicular parenchyma and epididymal changes.
Ongoing Management and Objectives
- Patients with an identifiable intrascrotal lesion should be sent for specialty urologic referral as they can be cured by a surgical procedure with a success rate of 50% on average. Superior results are obtained in the treatment of conditions such as painful hydrocele, spermatocele and varicocele.
- Patients with identified extragenital disease (spinal disorders, nerve entrapment) should be treated according to the cause.
- After complete evaluation, those patients without identifiable lesions must primarily be treated by the referring provider as follows:
- All active duty service members should receive duty limitations including: No running, no jumping, no ruck marching, no strenuous activity and no lifting greater than 10 pounds for one month prior to specialty Urology referral.
- All patients should be treated with an empiric course of antibiotics for two weeks (a flouroquinolone is preferable) and non-steroidal anti-inflammatory medications for six weeks prior to specialty Urology referral.
Indications for Specialty Care Referral
Initial screening evaluation demonstrates an abnormal scrotal finding such as such as testis tumor, hydrocele, spermatocele, and varicoceles.
Medical management fails after six weeks.
Elevated PSA (greater than 4.0), abnormal urinalysis, males with urinary tract infections (anatomical abnormalities of the urinary tract are commonly found in men infected with Gram negative enteric organisms and further investigation of the urinary tract should be considered in all such patients.
Criteria for Return to Primary Care
Patients will be referred back to primary care after full evaluation shows no demonstrable surgical defects or when the treatment results in the desired resolution of pain.
