Chronic testicular pain has a variety of potential causes. All men with chronic orchialgia should have a high-resolution scrotal ultrasound with color-flow Doppler to completely evaluate the scrotal contents and rule out any underlying pathologic process, such as a testicular tumor.
Successful treatment requires identification of the cause so that specific therapy can be instituted.Chronic EpididymitisA persistently tender, indurated epididymis, especially one associated with a positive semen or urine culture after an adequate cleansing of the genital skin, suggests chronic epididymitis. Therapy should be instituted using specific antibiotics depending on the results of the cultures.
Sitz baths and nonsteroidal anti-inflammatory agents should also be prescribed. Diagnostic epididymal puncture should never be performed in men desiring fertility because of the high risk of epididymal obstruction. Recurrent urinary tract infections, especially if associated with urethral strictures, may cause infected urine to reflux up the ejaculatory ducts and result in epididymitis.
Treatment of the stricture and appropriate antibiotics are indicated. For chronic epididymitis unresponsive to conservative measures such as antibiotics, anti-inflammatory agents, and sitz baths, total epididymectomy, as described earlier in this chapter, is curative and appropriate, especially for men in whom fertility is no longer an issue.
PostHernia Repair Orchialgia
Chronic testicular pain after hernia repair may be associated with nerve entrapment injuries . These usually will resolve with conservative therapy. If they do not, inguinal exploration and removal of any nonabsorbable suture materials may result in relief. For this reason, I recommend the use of nonabsorbable suture materials such as 2-0 PDS for hernia repairs. Mesh repairs can result in nerve entrapment either from the mesh itself or from the sutures used to sew the mesh in. Sewing the mesh in with absorbable sutures, which will eventually dissolve, reduces the likelihood of posthernia repair discomfort.
Large varicoceles can cause a persistent, aching discomfort often described by patients as a heavy sensation or a sensation of increased heat in their scrotum. This is almost always relieved when patients are in the supine position because their varicocele will collapse. Patients presenting with typical varicocele pain along with a clearly palpable large varicocele that collapses in the supine position will usually respond to microsurgical varicocelectomy
Postvasectomy Pain Syndromes
Postvasectomy chronic orchialgia is disappointingly common and difficult to treat . Although early pain lasting a few weeks is fairly common after vasectomy, present in up to 30% of men, long-term pain requiring some kind of interventional or surgical therapy probably occurs in approximately 1 in 1000 vasectomized men.
Chronic Intermittent Torsion
Men with chronic intermittent torsion have a history of episodes of sudden onset of testicular pain, as in acute testicular torsion. The pain is often associated with nausea. They may also observe that the testis is elevated and transverse-lying with a variable degree of scrotal enlargement from edema. However, the pain with intermittent torsion spontaneously disappears after anywhere from a few minutes to a few hours. In men with a recurrent history of this type of pain, scrotal orchiopexy as described earlier is usually curative. Prophylactic orchiopexy of the contralateral testis is recommended at the same sitting.
Chronic Orchialgia of Undetermined Etiology
The underlying etiology of chronic orchialgia may not always be obvious. Lower urinary tract symptoms, distal ureteral stone, occult hernia, irritable bowel syndrome, and referred pain are some of the possible causes of the symptoms. Even when no specific etiology can be found, conservative therapy, including nonsteroidal anti-inflammatory agents, sitz baths, and scrotal support for a period of 3 to 6 months, is indicated.
Not infrequently, these patients may fail conservative management, including pharmacologic, local anesthesia, and even psychological/behavioral therapy. Microsurgical total denervation of the spermatic cord is a measure with reported success in 80% of cases in several small series . Denervation is performed by mobilizing the spermatic cord, as in varicocelectomy, preserving the vas deferens, vasal vessels, testicular artery, and one or two lymphatics while transecting the rest of the cord .
The goal of the procedure is to denervate the testis by transecting all the nerve fibers of the genitofemoral nerve. Under the operating microscope, spermatic nerves appear as 0.2 to 1 mm diameter almost transparent structures that can be distinguished from lymphatics by characteristic transverse white striations
آدرس مطب : اصفهان ، خیابان شمس آبادی ، مقابل بیمارستان عیسی بن مریم ، ساختمان 71
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