ll Pain: Solving mysteries of the male scrotum

@DrAshBowen

On the Docket

• Good– Hydrocele

– Epididymal cysts

– Varicocele

• Bad– Testis Cancer/Tumor

– Epididymitis/Orchitis

– STI

– Torsion

• UGLY– Chronic Orchalgia

– Post Vas Syndrome

– Spousal Revenge Syndrome

Objectives

• Describe conditions that may produce scrotal pain

• Determine which scrotal conditions require emergent surgery

• Form an accurate differential diagnosis for scrotal pain

• Establish a pathway for the treatment of chronic orchalgia

Disclosures

I DO NOT want to be the ball pain king of Oklahoma

I DO NOT have any financial conflicts of interest.

Hydrocele

• Cause• Differential• To US, or not to US• Treatment

– Surgery– Drain/sclerose

• Cause

• Differential

• To US, or not to US

• Treatment – Surgery– Drain/sclerose

Epididymal Head Cyst (Spermatocele)

• Exam

• Reassurance

• Diff Dx

• Surgery only if bother• Reassurance• 17% risk of obstruction

with removal

Varicocele

• 15% of all males– 10% with pain,

• Si/Sx– Pain– Infertility– Hypogonadism

• Surgery• Outcomes

– 2.8x more likely to get pregnant

– 60-90% pain relief– Improvement in Testosterone

levels

The Red Herrings

• Nephrolithiasis

• Appendicitis

• Back pain, Lumbar disc herniation

• Neuropathy

Epididymitis/Orchitis

• DO NOT GIVE CIPRO• DO give NSAIDs• Rule out torsion• CDC Guidelines

– <35 yo Ceftriaxone 250mg IM &/or Doxy 100mg bid x10d

– ≥35 yo Levofloxacin or Oflaxacin x 10 days (add ceftriaxone in MSM

• 4-6 weeks may be needed for chronic epidiymitis

Vaccines Cause Adults

• Mumps Orchitis

– Sudden onset orchalgia, swelling

– Abdominal pain, nausea & vomiting

– Preceded by parotitis

– Supportive treatment

Testicular Torsion• Generalized testicular

pain & absence of cremasteric reflex

• Other: Nausea 10-60%, scrotal swelling late

• Associated with rest or activity

• Decreased Reliability of CDUS– Sensitivity 63-90%

Torsion Continued…

• Outcomes

– Risk of Orchiectomy

• 5% at 0-6 hrs

• 80% at 24 hrs

• 75% of “saved” testes will atrophy if >24hrs

Fournier’s Gangrene

• When to walk…– Fever, chills, malaise

– Erythema, swelling, pain, warmth

• When to run…– Fetid odor

– Necrosis

– Pain out of proportion to exam

– Air

Chronic Orchalgia

• ~5% of Urology patients

• 18% may never get satisfactory explanation

– 40% may be idiopathic

• History and Physical are key

– What antibiotics?

– Rectal exam, pelvic floor

UPOINT

First Line Treatment

• NSAIDs

– Meloxicam 7.5-15mg daily

– Ibuprofen 600mg TID

• Antibiotics

– 4-6 weeks

– Appropriate medication

• <35 doxy, >35 levaquin

Pelvic Floor Physical Therapy

• Can be curative in up to 80%– Neuromuscular re-

education (EMG, Biofeedback)

– Manual therapy (Soft tissue mobilization, Myofascial release, Connective tissue mobilization)

2nd Line Treatment

• Tricyclic Antidepressants

– 27% Major depression, 56% somatization disorder

– Amytriptyline 10-25mg daily

– Nortriptyline 10-150mg daily

• Lyrica/Gabapentin

– Gabapentin 300mg TID

– Pregabalin 50mg TID

Cord Block and Trigger Point

Surgical Therapies

• Microscopic Cord Denervation

– At 6 mo, 86% improved, 52% pain free

• Epididymectomy

– Complete response 10%, Partial response 88-90%

• Orchiectomy

– Decreased pain in 40-75%

Calixte et al. CurrUrol Rep. 2017.

Strohm et al. J Urol. 2008.

Epididymectomy

Hinman et al. Atlas of Urologic Surgery, 2nd Ed.

Microscopic Cord Denervation

When all else fails…

• Spinal cord stimulation

– In-office test

– 86% improved

– VAS from 7.6 to 2.4

– Small series

• Cord cryoablation

– 70% improved, 5% resolved

• Scrotox

– 62% improved, 7.5% resolved

#SQ788 • Canadian Meta-analysis, 169 pts with neuropathic pain, 6 trials

• All trials showed statistically significant decrease in pain, longest trial 8 weeks

• Only 3 of 6 showed clinically significant improvement (2pts on 10 pt VAS, 30% improvement)

• Safe, well tolerated

Deshpande et al. Can FamPhysician 2015

Post Vas Pain • 15% early after vasectomy

– <1% beyond 6 months

• Start with NSAIDs, scrotal support, ice/heat

• Surgical Efficacy

– Excision of granuloma

– Epididymectomy ~50%

– Vas reversal ~69%

– Nerve ligation 75-85%

– Orchiectomy 55% scrotal, 73% inguinal

Spousal Revenge Syndrome

• Occurs in men who have some type of sexual encounter outside of committed relationship

• Symptoms of STD

– Work up negative

• 100% pelvic floor spasm

– Treat with PFPT

• May also occur in female spouse after husband admits infidelity

Pediatric Scrotology

• Rule out torsion

• Epididymitis

– If pyuria antibiotics, if UA normal supportive management

– If post-pubertal, low threshold to treat for GC/Chlamydia

• Perinatal torsion

• Torsion of the Appendix Testis

Pediatric Scrotology Cont…

• Henoch-Sch ሷ𝑜nlein purpura

– Scrotal findings in 2-38%

• Edema, erythema, hematoma, torsion, epididymitis

• Choose Wisely

– Don’t routinely order US on boys with cryptorchidism

Conclusions

• You can do a lot with out an ultrasound, use your fingersound

• You can make a big difference in men with chronic orchalgia before they see a urologist

• Don’t fear the scrotum

• Get an Ultrasound on kids with acute scrotal pain

THANK YOU!

• QUESTIONS

• Contact info

– Ashley-Bowen@ouhsc.edu

– (405) 340-1279

– @DrAshBowen