II. History

  1. Characteristics of Testicular Pain
    1. Duration of pain (chronic defined as >3 months)
    2. Location of pain
    3. May be unilateral or bilateral
  2. Associated urologic symptoms
    1. Hematuria
    2. Hematospermia
    3. Dysuria
    4. Erectile Dysfunction (Impotence)
  3. Previous urologic surgery
    1. Vasectomy
    2. Genital Trauma
    3. Prior Hernia Repair
  4. Comorbid conditions
    1. Major Depression

III. Causes

  1. Idiopathic in 25% of cases
  2. Intermittent Testicular Torsion
  3. Post-genitourinary surgery
  4. Sperm granuloma (post-Vasectomy)
  5. Varicocele
  6. Testicular Cancer (painless in 60% of cases)
  7. Genitourinary infection (e.g. Sexually Transmitted Disease)

IV. Evaluation

  1. Assessment for Acute Testicular Pain is critical
  2. Assess for referred pain
    1. Nephrolithiasis in the mid-ureter (most common)
    2. Radiculopathy
      1. Genitofemoral and ilioinguinal nerves (T10-L1)
      2. Causes
        1. Inguinal Hernia
        2. Radiculitis
        3. Entrapment Neuropathy after Hernia Repair
        4. Sperm granuloma

V. Signs

  1. Complete Male Genital Exam including rectal exam

VII. Radiology

  1. Ultrasound with color flow doppler of Scrotum
  2. Consider Spiral CT Abdomen or intravenous pyelogram

VIII. Management

  1. Step 1
    1. NSAIDs
    2. Adjust Posture if due to radiculopathy
    3. Empiric antibiotics for 2 weeks or more
      1. Cover Chlamydia and Ureaplasma
      2. Doxycycline
      3. Ciprofloxacin
  2. Step 2
    1. Spermatic cord block at pubic tubercle
      1. Bupivicaine (Marcaine) 0.25% 3 ml and
      2. Methylprednisolone 40 mg
      3. Inject no more often than once monthly
    2. Trascutaneous Electrical Nerve Stimulation (TENS)
  3. Step 3
    1. Multidisciplinary Pain Management
    2. Antidepressant medication
    3. Psychotherapy
  4. Step 4: Urologic Surgery
    1. Orchiectomy
    2. Surgical denervation Testes alon spermatic cord

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