Chronic scrotal pain

Specialty: Nephrology and urology.

• chronic orchialgia
• persistent testicular pain
• chronic scrotodynia

Why it occurs

• Persistent varicocele (especially on the left side, where chronic venous congestion and valvular incompetence of the internal spermatic vein cause constant dull discomfort)
• Chronic orchiepididymitis (bacterial or non-bacterial inflammation or infection of the testicle or epididymis lasting more than 3 months, with tissue fibrosis)
• Neuropathy of the ilioinguinal or genitofemoral nerve (entrapment or injury of the sensory nerve branches after previous surgeries such as inguinal herniorrhaphy, vasectomy or varicocele surgeries)
• Referred testicular pain of extrascrotal origin (due to L1-L2 lumbar compressive radiculopathy, root compression, impacted distal urethral lithiasis or chronic prostatitis)
• Idiopathic chronic scrotal pain syndrome (diagnosis of exclusion where no clear anatomical or pathological cause is identified after a thorough evaluation)

Initial workup

Scrotal ultrasound with high-resolution color Doppler (initial study of choice, essential to evaluate the testicular parenchyma, look for epididymal cysts, hydroceles, retrograde venous flows indicative of varicocele, or intratesticular nodules); urinalysis with sediment and culture; sperm culture to rule out stored germs; x-ray or MRI of the lumbar spine if compressive radiculopathy is suspected; diagnostic anesthetic block of the spermatic cord (performed by a urologist).

Standard management

• Pregabalin — 75-150 mg every 12 hours orally) or Gabapentin (300 mg every 8 hours orally; voltage-dependent calcium channel modulators indicated if a component of neuropathic pain or peripheral nerve entrapment is suspected
• Amitriptyline — 10-25 mg orally at night, tricyclic antidepressant very useful for the control of chronic idiopathic or refractory neuropathic pain
• Naproxen — 500 mg every 12 hours orally for cycles of a maximum of 10-14 days, alternating with rest periods to avoid gastric and renal toxicity
• Therapeutic infiltration of the spermatic cord with local anesthetics (such as 0.25-0.5% bupivacaine, associated or not with a corticosteroid such as triamcinolone, under ultrasound control or anatomical palpation by the urologist).