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MikaRaitanen

Testis Pain

Essentials

  • Diagnose and treat testis torsion immediately.
  • Treat epididymitis with antimicrobials. In adolescents, remember the possibility of a chlamydia infection.
  • Diagnose varicocele as a cause of prolonged testis pain.
  • In association with acute abdominal pain, remember to examine the testes.
  • Vasectomy and inguinal hernia repair are associated with the risk of chronic scrotal pain, of which patients should be informed in advance.

Testis torsion

  • The aetiology of acute testis pain is testis torsion until proven otherwise.
  • Typical patients are children and adolescents who are not yet sexually active, but testis torsion can also occur in adults.
  • Pain, which may initially be felt only in the lower abdomen and only later in the scrotum, and unilateral swelling of the scrotum start suddenly.
  • The testicle may rise into the upper part of the scrotum and lie there horizontally, but in the initial phase, tenderness of the testicle often is the only finding.
  • Torsion of appendix testis and epididymitis may resemble testis torsion. The differential diagnosis can often be made only in an operation.
  • Testis torsion should be treated with an urgent operation to untwist the torsion and to fix both testicles in place within the scrotum.

Epididymitis

  • Swelling and tenderness are located in the epididymis, but the testis itself may also be tender. The scrotum is often swollen, reddened and hot.
  • Symptoms associated with urination are often present: pain, burning and frequency.
  • The causative agents include bacteria causing urinary tract infections, and in sexually active patients also chlamydiae and sometimes gonococci. In older men retention problems often constitute a predisposing factor.
  • Epididymitis occurs also before the sexually active age.
  • In children epididymitis is apparently caused by the passage of sterile or infected urine to the deferent duct. In recurrences, ultrasonography of the urinary tracts is a worthwhile examination for excluding e.g., ectopic ureter. Attention should also be paid to enuresis and difficulties in voiding.
  • In all age groups manipulation of the urethra, such as prolonged indwelling catheterization and urological interventions, predispose to epididymitis.
  • Investigations
    • CRP
    • Chemical urinalysis and urine culture
    • Nucleic acid testing for chlamydia and gonorrhoea
  • The initial treatment in children consists of trimethoprim-sulphamethoxazole or a cephalosporin derivative, and of a fluoroquinolone in other patients. The treatment is adjusted according to sensitivity testing. Long courses of fluoroquinolones should be avoided. Duration of treatment is 2 weeks.
  • A suspensor to support the scrotum, cool bandages, and NSAIDs relieve pain.

Orchitis

  • The swelling is located in the testis itself.
  • Orchitis is very uncommon in countries where mumps has disappeared as a result of vaccinations, but may be associated with epididymitis (epididymo-orchitis).
  • The differential diagnosis of orchitis and testicular torsion is difficult (refer to hospital urgently if there is the slightest doubt).
  • Investigations
    • Parotitis serology (paired serum samples) from the unvaccinated
  • Treatment
    • Pain relief (see above)

Varicocele

Chronic scrotal pain

  • In chronic scrotal (content) pain (CSP or CSCP, respectively), the pain may be felt in a testis, epididymis and/or vas deferens.
  • A single cause for the pain can rarely be established.
    • Of single causes, the most common are pains following vasectomy and inguinal hernia repair.
    • About 15% of patients experience scrotal pain 6 months after vasectomy.
    • In about 1% the pain disturbs daily life.
    • Pain occurs less frequently when non-scalpel technique is used.
    • After inguinal hernia repair, about 10% of patients have chronic pain, which is why only symptomatic inguinal hernias are operated.
  • Ultrasound examination of the groins and the scrotum is recommended, to exclude, for example, inguinal hernia and testicular cancer.
  • Multiprofessional treatment provided by, for example, an outpatient pain clinic may be beneficial.
  • Sometimes pain following vasectomy can be relieved by reconnecting the vasa deferentia (vasovasostomy).
  • If spermatic cord anaesthesia block (SCAB) relieves the pain, microsurgical denervation of the spermatic cord may be beneficial.

    References

    • Hetta DF, Mahran AM, Kamal EE. Pulsed Radiofrequency Treatment for Chronic Post-Surgical Orchialgia: A Double-Blind, Sham-Controlled, Randomized Trial: Three-Month Results. Pain Physician 2018;21(2):199-205. [PubMed]
    • Tantawy SA, Kamel DM, Abdelbasset WK. Does transcutaneous electrical nerve stimulation reduce pain and improve quality of life in patients with idiopathic chronic orchialgia? A randomized controlled trial. J Pain Res 2018;(11):77-82. [PubMed]