What is chronic testicular pain ?
A small percentage of men who have previously undergone vasectomy, hernia surgery, kidney removal, scrotal or pelvic trauma, recurrent epididymal / testicular infections present with chronic testicular pain. This pain may range from a mild irritation to severe debilitating pain that impacts the patient's quality of life significantly.
What causes chronic testicular pain ?
The reasons are not quite clear. One theory is that the sensory pain fibers running along the spermatic cord may for some reason have a very low stimulation threshold due to previous scrotal surgery (vasectomy), hernia surgery, kidney removal, scrotal or pelvic trauma and recurrent epididymal / testicular infections.This could be due to local irritation / inflammation along these nerve fibers. For this reason, we try conservative therapies initially since a number of patients have spontaneous resolution of the pain after a period of observation. This period may range from a few months to a few years. Our goal is to provide maximal comfort and relief for the patient from a quality of life standpoint with minimal risk - so if a patient has significant pain impacting their daily activities, more aggressive surgical intervention may be pursued at that point. This nerve hyper-stimulation can create extraordinary pain for the patient that is quite real, but cannot be defined as any structural abnormality by imaging modalities (these patients usually have a completely normal scrotal ultrasound). Our recommendation is generally not to perform any type of exploratory procedures on patients to remove possible staples and/or remove portions of the reproductive tract (epididymis/ testis/ scar tissue, etc) - since these additional procedures can sometimes aggravate the pain by further stimulating these already dysfunctional nerve fibers.
How is chronic testicular pain treated ?
Chronic testicular pain is usually initially managed using conservative therapies initially. A urologic workup is usually completed to ensure that there is no other contributing factor to this pain (this is usually done before patients come to see us by their primary urologists). If this workup is negative, a trial of oral anti-inflammatory, antibiotics, acupuncture or pelvic floor rehabilitation may be utilized. If any of these techniques fail, then we have developed some unique treatment options that may offer relief. Currently, we proceed straight to these treatment options based on patient symptoms because of the high success rates in eliminating pain compared to the poor success rates with conservative treatment options:
1) Mapped segmental spermatic cord block
A precise minimally invasive delivery of local anesthetics and anti-inflammatory agents at predefined locations along the spermatic cord to assess if specific nerve fiber de-activation provides pain relief for the patient. If this resolves the pain, then the pain is likely to be of a neurologic origin due to hypersensitive pain nerve fibers. The cord block usually only provides temporary relief (hours, days or weeks - depending on the individual patient and their baseline pain characteristics). A patient who responds to the cord block (even transiently) is likely to be a good candidate for robotic neurolysis of the spermatic cord which will usually provides permanent relief. Currently, we have also had many patients who even did not respond to the cord block respond to the robotic neurolysis and thus in many patients we may proceed directly to neurolysis without cord block. The nerve distribution is quite complex in the cord and we believe that we may miss some of the critical nerves with a cord block and may be able to do a more precise and more targeted lysis with robotic neurolysis.
2) Targeted Robotic assisted targeted microsurgical neurolysis of the spermatic cord
We perform a highly specialized targeted robotic assisted microsurgical dissection of the nerve fibers in the spermatic cord that we think are responsible for the pain and ligate them to hopefully achieve permanent pain relief. This technique involves a small 1-2 cm skin incision in the groin and then dissection through the spermatic cord in a minimally invasive manner. We are the leading center in the development of this technique and have achieved a complete or partial resolution of pain in up to 86% of our patients so far based on a validated pain impact score (the PIQ-6 score). This procedure is performed with real-time intra-operative Doppler identification and protection of the testicular arteries to prevent any potential testicular atrophy / injury. The robotic platform provides unparalleled 3 dimensional high definition visualization, refined surgical instrument handling (removal of any tremor) and the ability for the surgeon to utilize multiple instruments simultaneously (due to the additional robotic arm) to provide enhanced efficiency.
3) Robotic assisted microsurgical vasectomy reversal
In a small percentage of men who have previously undergone a vasectomy, there may be chronic testicular / groin pain. This pain can range from a mild irritation to debilitating pain that requires chronic pain medication use. In some of these men with specific findings of episodic pain, especially after ejaculation, or episodic pressure sensations, robotic assisted vasectomy reversal may be a treatment option. This modality is utilized if the patient does not respond to a cord block. Successful relief of pain may be achieved in up to 69% of patients undergoing microsurgical vasectomy reversal. In our preliminary small cohort of patients undergoing robotic vasectomy reversal for pain, we have achieved a higher pain resolution rate.
What can we offer patients with chronic testicular pain ?
Our center provides a unique multi-disciplinary approach to the evaluation and treatment of chronic testicular pain. Our mission is to provide the most innovative and reliable treatment options available for the management of this condition in a compassionate manner.
Peer Reviewed Publications on Chronic Groin/Testicular Pain:
Ramasamy R, Sterling J, Li PS, Robinson BD, Parekattil S, Chen J, Felsen D, Mukherjee S, Schlegel PN: Multiphoton imaging and laser ablation of rodent spermatic cord nerves. Journal of Urology, Feb 2012.
ParekattilSJ, Brahmbhatt JV:Robotic approaches for male infertility and chronic orchialgia microsurgery. Curr Opin Urol. 2011 Nov;21(6):493-9.
Parekattil SJ, Cohen MS: Robotic microsurgery 2011: male infertility, chronic testicular pain, postvasectomy pain, sports hernia pain and phantom pain. Curr Opin Urol. 2011 Mar;21(2):121-6.
Parekattil S, Ellen JH, Priola KB, Atalah HN, Cohen MS:Video technique of Single Port and Abdominal Robotic Microsurgical Neurolysis for Chronic Groin Pain or Orchialgia. Journal of Endourology, Part B: Videourology, January 2011. doi: 10.1089/vid.2010.0118
Parekattil SJ, Moran M: Robotic Instrumentation: Evolution & Microsurgical Applications. Special symposium-Novel instrumentation in urologic surgery.Indian J Urol. 2010 Jul;26(3):395-403.
Parekattil SJ, Cohen MS: Robotic Microsurgery in Male infertility and Chronic Orchialgia. Curr Opin Urol. 2010 Jan;20(1):75-9. Review.