What is Chronic Testicular Pain and Orchalgia (Chronic Testicular Pain)?
Chronic orchialgia is a condition where a person experiences testicular pain periodically or constantly for at least three months, and it’s serious enough to disturb their daily life. About 2.5% to 5% of all urology consultation cases are due to this condition, affecting around 100,000 men in the United States every year. The condition becomes more complex to understand and treat when there is no clear identifiable cause, termed as idiopathic chronic orchialgia.
Finding the underlying cause can be tricky as it’s often idiopathic, meaning it originates from an unknown cause. The initial steps of treatment frequently involve conservative therapy, but there are times when it doesn’t work, making this condition hard to diagnose and treat. If initial treatments do not work, doctors can resort to more aggressive methods. These can include options like spermatic cord blocks, varicocelectomy, epididymectomy, vasovasostomy (if the patient has had a vasectomy), microsurgical denervation of the spermatic cord (MDSC), botulinum toxin injections, and orchiectomy.
What Causes Chronic Testicular Pain and Orchalgia (Chronic Testicular Pain)?
Chronic testicular pain, also known as chronic orchialgia, can come from several different sources. Some of these can include complications like cysts in the testes, varicoceles (swelling in the veins that drain the testicle), infections, trauma, scar tissue formation, tumors, or twisting of the testes or their appendages. Other causes include back strain, inflammation of blood vessels (like in Henoch-Schonlein purpura), pain after a vasectomy, nerve damage from hernia surgery, muscle dysfunction in the pelvic floor, or even discomfort referred from elsewhere, like a kidney stone.
Some less common reasons for this chronic pain can include nerve damage from diabetes, tumors in the abdomen, a certain bladder condition called interstitial cystitis, abdominal aortic aneurysms (an enlarged main blood vessel), inflammation of the inner lining of the abdomen, inflammation of the tube that stores and carries sperm due to the drug amiodarone, certain muscle and bone disorders affecting the pelvis, a type of arthritis affecting the public bone, and a type of inflammation of small and medium-sized blood vessels known as polyarteritis nodosa. Chronic testicular pain can also be related to chronic pelvic pain syndrome. It’s important to note that up to half of the men who experience chronic pelvic pain or prostatitis, which is swelling and inflammation of the prostate gland, may also report chronic testicular pain.
The testicles receive feeling through nerves like the ilioinguinal nerve and the genital branch of the genitofemoral nerve. However, pain can be referred to the genital area from any organ or tissue that shares a nerve pathway with the scrotum or testes, such as the lower back. Problems such as back pain or nerve inflammation impacting nerve roots from T10 to L1 can lead to testicular pain. Similarly, issues or injuries impacting the nerves of the scrotum can be experienced as testicular pain.
A condition called Henoch-Schonlein purpura, where blood vessels become inflamed, is a less common cause of chronic testicular pain but should be considered, especially in patients younger than 20. This type of inflammation can cause marked swelling of the scrotum that can sometimes be misdiagnosed as a sudden testicular problem requiring surgery. Amiodarone is a medication that has been linked with a non-infectious inflammation condition in the tube where sperm is stored, in up to 11% of adults on the medication. This reaction is believed to occur because of the high concentration of the drug that can be found in testicular tissue.
There may also be a psychological component in chronic testicular pain, including mental health conditions like somatization disorder or major depression, chronic pain in other parts of the body, and chemical dependency. If no specific cause can be determined, which occurs in about 25% to 50% of all cases, the pain is considered idiopathic chronic orchialgia. This is thought to be due to inflammation of the nerves or nerve sensitivity possibly from prolonged overstimulation.
Risk Factors and Frequency for Chronic Testicular Pain and Orchalgia (Chronic Testicular Pain)
Chronic orchialgia, a type of long-lasting testicular pain, is most commonly seen in men in their mid to late 30s, and it’s becoming more common. It’s often linked with various health conditions and factors like male infertility, chronic inflammation of the prostate, pain in the lower back, stress, and irritable bowel syndrome, a disorder affecting the large intestine.
Signs and Symptoms of Chronic Testicular Pain and Orchalgia (Chronic Testicular Pain)
When identifying the cause of chronic testicular pain, it’s important to gather a full medical and sexual history, along with details of any surgeries. The doctor should note any links between the pain and certain activities like using the toilet, rigorous physical activity, sexual intercourse, or sitting for long periods. It’s also crucial to understand specifics about the pain, such as where exactly it is, what it feels like, when it happens, what makes it worse, how quickly it starts, and if it’s felt elsewhere in the body. For instance, sitting for a long time and constipation often make the pain worse for people with idiopathic chronic orchialgia (chronic testicular pain of unknown cause). Those with a bladder condition called interstitial cystitis typically experience pain above the pubic bone that’s linked to their bladder function.
During a physical exam, doctors should focus on the scrotum and genitals, examining the patient in both standing and sitting positions. They always begin with the side that’s not in pain. They will check every part of the testicle (testis, epididymis, and vas) for sensitive spots, swelling, and abnormal lumps. A digital rectal exam (an exam of the lower rectum) is carried out to check for prostatitis (inflammation of the prostate gland) and abnormal tension in the pelvic floor muscles. The aim of the examination is to pinpoint the specific organ or area that’s causing the pain, if possible.
Pelvic floor pain or muscle weakness could contribute to chronic testicular pain in certain men. For example, in one study, 93% of 41 men with chronic idiopathic orchialgia showed at least one symptom of pelvic floor dysfunction, and 88% of these men showed increased pelvic floor muscle tension during a test that measures the electrical activity of the muscles. Men who experience pelvic floor pain or tension during a digital rectal exam could find relief through pelvic floor physical therapy.
Mental health concerns can also play a significant role in chronic testicular pain, notably when no physical cause can be found. Chronic genital pain can be influenced by psychological issues such as sexual dysfunction, anxiety, history of sexual abuse, major depression, and somatization disorder (a mental illness that causes individuals to experience physical symptoms without an identified cause).
- Nociceptive pain: This type of pain is often described as dull or aching. It is typically triggered by gentle pressure on the testicles and may be linked to physical changes to the testicles like enlargement or shrinkage and atrophy. This is the type of pain you’d normally expect from something causing pain.
- Neuropathic pain: This type of testicular pain is typified by a burning sensation, having excessively heightened (hyperesthesia) or reduced (hypoesthesia) senses, and pain radiating to the skin of the scrotum. It is normally caused by an injury in the nervous system, which is not necessarily near the painful area and is usually located in the central or peripheral nervous system. Activities like walking, bending over, or overextending the hip might trigger the symptoms. Lying down and bending the thigh can sometimes bring relief.
- Allodynia: This is a condition where something that usually doesn’t cause pain is perceived as painful.
Testing for Chronic Testicular Pain and Orchalgia (Chronic Testicular Pain)
When a patient has chronic orchialgia – long-term pain in the testicles – several tests are typically required. These include a urine test and, for some patients, a semen culture. It’s common for people with this condition to have low levels of testosterone and B-12, so these levels may also be checked. In some cases, therapies to restore these levels can help ease the pain.
The main test to diagnose chronic orchialgia is scrotal ultrasonography, which uses sound waves to create images of the scrotum and testicles.
In certain cases, a CT scan of the lower abdomen and pelvis may be necessary. This scan can check for ureteral stones, aneurysms, or inguinal hernias, which are conditions that could be causing or adding to the pain. A spinal MRI, on the other hand, is only occasionally recommended and usually only for patients who also have back or hip pain. Procedures like cystoscopy, voiding cystourethrography, and retrograde and intravenous pyelography, which are different types of imaging tests, usually don’t help diagnose the condition and aren’t typically recommended.
Because diagnosing chronic orchialgia can be tricky, it’s not uncommon for patients to see several different doctors and undergo many tests. In fact, on average, patients go through about 5 to 7 diagnostic tests and 1 to 2 surgical procedures.
Treatment Options for Chronic Testicular Pain and Orchalgia (Chronic Testicular Pain)
A team approach involving pain management experts, psychiatrists, pelvic floor physical therapists, primary care practitioners, and urologists is recommended when treating patients with chronic testicular pain. Conservative treatments, such as physical therapy, should be explored before considering invasive, irreversible surgeries.
The exact treatment of chronic testicular pain varies as there aren’t exact guidelines. If a clear cause of the pain is identified, such as hernias or epididymitis, the treatment targets this issue. If treatment fails or no clear cause is found, a variety of less aggressive therapies are tried.
Non-aggressive therapies include heat, ice, scrotal support, antibiotics, painkillers, antidepressants, anticonvulsants, nerve blocks, pelvic floor physical therapy, biofeedback, acupuncture, and psychotherapy. Conservative therapies should ideally be tried for at least three months, even though the success rate ranges from 4.2% to 15.2%.
In terms of lifestyle changes, it is often advised for patients to eliminate caffeine, citrus fruits, hot spices, and chocolate from their diets. Moreover, they should avoid constipation and excessive sitting.
If traditional painkillers aren’t sufficient, antidepressants or anticonvulsants are sometimes used. This is due to their ability to help manage nerve-related pain. While their benefits may not be apparent for several weeks, some studies have reported significant pain relief in over 60% of patients.
Dry needling treatments, performed indirectly through the skin, are found to be effective in about 85% of patients. For instance, physical therapy focusing on the pelvic floor muscles can help alleviate pain in half of the patients after 12 sessions.
Surgical intervention is typically a last resort, considered if pain decreases by at least half with a spermatic cord block. Here, the nerves within the spermatic cord are numbed to provide temporary relief.
When a patient has had a vasectomy and starts to experience chronic pain, a vasectomy reversal might help. This is especially true if the pain is associated with sexual activity or if the patient has a large accumulation of sperm in the epididymus, which is just above the testicle.
There are other surgical procedures such as microsurgical denervation of the spermatic cord which can help to treat pain in the testicle. They have brought about the improvement in most of the cases. However, their positive effects are usually most pronounced when the patient has achieved noticeable pain relief from less invasive treatments such as a spermatic cord block.
These are a multitude of surgical procedures, each with their own risks and benefits. For disconnected patients, even the surgical removal of a testicle may be offered if other treatment options have failed. It’s essential, however, that you discuss each option thoroughly with a healthcare professional.
What else can Chronic Testicular Pain and Orchalgia (Chronic Testicular Pain) be?
- Hydrocele (a collection of fluid in the testicle)
- Non-seminomatous tumors (a type of testicular cancer)
- Orchitis (inflammation of the testicles often caused by infection)
- Scrotal trauma (damage caused by an injury to the scrotum)
- Spermatocele (a fluid-filled cyst in the testicle)
- Seminoma (a type of testicular cancer)
- Testicular torsion (a twisted testicle causing severe pain and swelling)
- Testicular tumor (an abnormal growth in the testicle)
- Testicular trauma (damage caused by an injury to the testicle)
- Varicocele (an enlargement of the veins in the scrotum)
