CHRONIC TESTICULAR PAIN: A DIFFICULT AILMENT TO CURE

In urology practice many a times we encounter cases of chronic testicular pain .The patient gives with a long history of treatment and investigations.Having failed with different painkillers , antibiotics, hetrazan etc patient runs from one doctor to the other.

There are many causes for testicular pain; chronic infections,hydrocele, varicocele,trauma, previous surgery,post vasectomy pain .Sometimes a serious underlying disorders like Genitourinary tract tuberculosis and testicular malignancy can present with pain.The pain can be continuous or intermittent.The usual intensity of the pain is deep dull aching.Prolonged sitting,standing,jogging,exercise can aggravate the pain.It is often accomanied with low backache.

The correlation of the backache and the testicular pain is often due to  chronic prostatitis .In other cases it can be a coincidence only. 

Some patients get testicular pain  post herniorrhaphy or hernioplasty.This pain is commonly due to entrapment of the ilioinguinal nerve.This neuralgic pain can be shooting in nature.

Testicular pain often makes the patient restless.We have seen patients getting frustrated as the pain  refuses to go away even after multiple courses of antibiotics and analgesics.The victims are usually young.These people often are worried about the effect of the  pain on sexuality and fertility.Some people think that persistence of pain could be due to undiagnosed malignancy.We have seen patients browsing on net regarding testicular cancer and getting repeated ultarsounds.

There is a pessimistic outlook for chronic testicular pain from the urologists side also. What is more important is to reassure the patient that the pain is more of a nuisance and unlikely to affect the sexual life and fertility.They also need to be counselled regarding absence of malignancy.

We make it a point to thoroughly convince the patient that the pain is not a health hazard.We educate them about the disease and advise them not to browse about testicular pain unnecessarily.browsing and reading unrelated information for example regarding testicular cancer can make them demoralised.

All patients with chronic testicular pain are evaluated at our hospital thoroughly for any infective aetiology, any bladder outlet obstruction or GUTB.If the patient has varicocele then we advise them to wear scrotal support( if the spermatic parameters are not affected).If the sperm count is low then we usually advise them microsurgical varicocelectomy.

A course of hetrazan ( 100mg twice a day for 21 days) is usually given if not administered previously.

As there is no precise protocol or guidelines to treat the chronic testicular pain; every urologist has there own way of treating them.We at Ramayya Pramila treat the chronic idiopathic testicular pain with a course of gabapentin or  pregabalin. Sometimes we also give carbamazepine.If these drugs also fail then we decide to go ahead with microsurgical denervation of the spermatic cord.

The microsurgical denervation treatment has been successfully instituted at Ramayya Pramila for many refractory testicular pain patients.We give a spermatic cord block as a trial.If the pain gets significantly alleviated then we propose the microsurgical denervation.

Anatomic considerations of nerve supply of the testis:

This occurs via somatic nerves in the genital branch of the genitofemoral and the ilioinguinal nerves, as well as autonomic branches from the parasympathetic ganglia of T10–12 for the testis, and T10–L1 for the epididymis and vas deferens. It should be recognized that there is significant crossover and overlap of sensory input from the ilioinguinal, iliohypogastric and genitofemoral nerves. There are noci-receptors (  somatic and visceral free nerve endings which are activated by noxious stimuli) which sense the sensations of pain and discomfort.  The nerves carrying pain are  myelinated A delta fibers, as well as unmyelinated C fibers. Impulses are ultimately carried to the dorsal horn via intraspinal nerve routes and the pain message travels cephalad via the medial and lateral spinothalamic tracts to the brain.

Microsurgical denervation of the spermatic cord:

This procedure is done through the inguinal approach.We use magnification of 10-15X and perform cremasteric release.After opening and stripping the cremasteric box; we ligate and divide internal spermatic veins if any.Then we denude all the cord structures of any fascia and  nerves.

The final appearance should look like bare vas, artery and lymphatics.We cover the pre-operative and 2 week postoperative period with pregabalin. 

MICROSURGICAL DENERVATION OF THE SPERMATIC CORD AT RAMAYYA PRAMILA : CORD IS LEFT WITH ONLY VAS, ARTERY AND LYMPHATICS...A DENUDING OF THE SPERMATIC CORD

          

In special situations:

Pain after vasectomy:

if conservative measures fail then we do vasovasostomy( vasectomy reversal).The pain after vasectomy is often due to congestive epididymitis .The reversal restores the sperm fluid flow and the congestion subsides.

Pain due to chronic epididymitis( either bacterial or granulomatous): We have done epididymectomy with excellent results. 

Orchiectomy is reserved as a last resort when all other measures fail and the pain is incapacitating affecting patients quality of life.