GENITAL PAIN SYNDROME
Semir A. S. Al Samarrai
Scrotal pain Syndromes
Scrotal pain syndrome is a generic term and used when the site of the pain is not clearly testicular or epididymal. The pain is not in the skin as such, but perceived within the contents in similar way to idiopathic chest pain (1).
This Syndrome is defined as the occurrence of persistent or recurrent episodic pain localized within the organs of the scrotum, which may be associated with symptoms suggestive of urinary tract or sexual dysfunction. There is no proven infection or other obvious local pathology (1).
This syndrome is after associated with negative cognitive behavioural, sexual or emotional consequences (1).
The pathogenisis of this chronic pain in the scrotum is diverse and in most cases unknown. Pain in the scrotum can be divided into direct pain localized in the scotum, or referred pain coming from another place or system in the body. The problem is that we cannot always make that division in clinical practice. Direct pain is located in the testes, epididymis, inguinal nerves or the vas deferens (1).
Testicular Pain Syndrome
Testicular pain syndrome is the occurrence of persistent or recurrent pain perceived in the testes and may be associated with symptoms suggestive of urinary tract or sexual dysfunction. There is no proven infection or other obvious local pathology.
Testicular Pain syndrome is after associated with negative congnitive, behavioural, or emotional consequences, as well as with symptoms suggestive of lower urinary tract and sexual dysfunction. Previous terms have included orchitis, orchalgia and orchiodynia. These terms are no longer recommended (1).
Epididymal Pain Syndrome
Epipidymal Pain Syndrome is the occurrence of persistent or recurrent episodic pain perceived in the epididymes, which may be associated with symptoms suggestive of urinary tract or sexual dysfunction. There are no proven infections or obvious local pathology. Epididymal Pain Syndrome is often associated with negative congnitive, behavioural, sexual or emotional consequences as well as with symptoms suggestive of lower urinary tract and sexual dysfunction (1).
Structural abnormalities of the epididymis can be visualized using ultrasound. Patient with multiple cysts may have pain caused by the compression the these cysts exert on the epididymis. Another local entity is chronic epididymitis (2). Chronic epididymis may be associated with signs of inflammation: inflammatory or obstructive chronic epididymitis (3).
Urethral-pain Syndrome is the occurrence of chronic or recurrent episodic pain perceived in the urethra. Based on the definition, there is no well-known pathogenetic mechanism responsible for urethral pain-syndrome. It is obvious that what might cause pain in bladder could be responsible for urethral pain. Mechanisms thought to be basis for Bladder Pain Syndrome also apply to the urethra. This means that specific testing with potassium is used to support the theory of epithelial leakage (29, 30).
Urethral Pain Syndrome is supposed to be the same as BPS in that the epithelium is leaking, thereby causing pain.
Another possible mechanism is the neuropathic hypersensitivity following urinary tract infection (31).
The Ilioinguinal and genitofemoral nerves are the most prominent afferent nerves for the scrotum (4). The inguinal nerves are especially important. It is generally accepted that pain after surgery (hernia) is a consequence of damage to the nerves inside the spermatic cord (5). This is based on the anatomical knowledge that all nerves involved in testicular pain merge in the spermatic cord (6).This fact has consequences for the choice of treatment. The pudendal nerve supplies the skin of the perineum and the posterior side of the scrotum. Pain in this area is pathogenic for pudendal neuropathy.
Post-Vasectomy Pain Syndrome
Post-vasectomy Scrotal Pain Syndrome is a scrotal pain that follows vasectomy. Post-vasectomy scrotal pain syndrome is often associated with negative cognitive, behavioural, sexual, or emotional consequences, as well as with symptoms suggestive of lower urinary tract and sexual dysfunction.
Pathogenetically, it is thought that post-vasectomy pain is caused by the fact that the vas deference is no longer patent. This may lead to congestion in the epididymis which in turn given rise to pain because of dilatation of hollow structures (7). Incidence of post-vasectomy pain is 2-20% among all man who has undergone a vasectomy (8).
Post-inguinal Hernia Repair
Chronic pain after inguinal hernia surgery is well recognized phenomenon. An international working group has set up guidelines for prevention and management of post operative chronic pain following inguinal hernia surgery. They have stated that the most important way of preventing pain is to identify and preserve all three inguinal nerves (9).
Chronic scrotal pain is a complication of hernia repair. In almost all studies, the frequency of scrotal pain was significantly higher in the laparoscopic than in the inguinal hernia repair (5, 10, 11, 13).
Physical examination is mandatory in patients with scrotal pain. Gentle palpation of each component of the scrotum is performed to search for masses and painful spots. A rectal examination is done to look for prostate abnormalities and to examine the pelvic floor muscles. Scrotal ultrasound has limited value in finding the cause of the pain. In > 80% of patients, ultrasound does not show abnormalities that have clinical implication (13, 14). If physical examination is normal, ultrasound can be performed to reassure the patient that there is no pathology that needs therapy (mainly surgery). Ultrasound can be used to diagnose hydroceles. Spermatoceles, cysts and Varicoceles. When abnormalities such cysts are seen, this may play a role in therapeutic decision making (15).
Treatment of Chronic Scrotal Pain is based on the principles of treating chronic pain syndromes. It is becoming increasingly clear that advances in the non-surgical management of testicular pain one mainly based on the emergence of pain relief as a specialty. Knowing this, it seems obvious that referring to a multidisciplinary pain team or pain centre should be considered in an early phase of the consultation (16). By doing this, surgery can be postponed or even avoided.
For conservative treatment, apart from pharmacotherapy, myofascial therapy by specialized physiotherapists should be considered. The pelvic floor muscle should be tested and will be often be found overactive, which means that they contract when relaxation is needed. An overactive pelvic floor should be treated by physiotherapy (17, 18, 19).
More specific myofascial trigger points are found in the pelvic floor, but also in the lower abdominal musculature. Treatment consists of applying pressure to the trigger point and stretching the muscle (20, 21).
In a survey among Swiss Urologists, it was found that 74% would do an urologists epididymectomy, 7% an inguinal Orchiectomy, and 6% a denervation (15). In the literature, there is consensus on postponing surgery until there is no other option. The only treatment that seem be effective is microsurgical denervation.
Epididymectomy is a choice in selected cases and orchiectomy is the last resort.
Microsurgical denervation or under magnification by Loupe. Considering the fact that all the nerves for the scrotal organs merge into the spermatic cord, it seems reasonable to cut all nerves in patients with pain. All the studies that have been done were cohort studies but their success rates were high. The indications criteria for this procedure in three cohort studies were patients with chronic scrotal pain, who did not respond to conservation treatment. Ultrasound showed by the patients no abnormalities and a spermatic block shown pain relief of >50%.
The surgical approach is inguinal, the surgery is performed under magnification by Loupe or microscope. Complete relief of pain is achieved in 71-96%, and patient relief in 9-17%.
This means that 12-15% had no relief of pain after denervation.
The complication of testicular athropy was seen in 3-7% of the operated patients (22, 23, 24, 25, 26, 27).
There is no difference in success based on the cause of pain. The laparoscopic route for denervation seem feasible but the result are unclear (25).
There is to date no hard evidence available, but expert opinion is clear that Orchiectomy should be reserved for patients who have undergone denervation but still have pain (1).
Epididymectomy showed best results in patients with pain after vasectomy, or pain by palpation of the epididymis and when ultrasound shows multiple cysts.
The percentage of patients that are cured ranges from 50-92% (1,7, 26, 27, 28).
Orchiectomy is seen as the last resort in patients with intrascrotal pain, who do not respond to any other treatment. There have been no studies that can help in making a rational decision on whether to perform Orchiectomy (1).
In post vasectomy pain syndrome, a vaso-vasostomy might help to overcome the obstruction and thereby improve the pain. Some studies have shown good results but the quality of these studies was limited. Results are as high as 69-84% (1).
Treatment of Urethral Pain Syndrome
There is no specific treatment that can be advised (29). Management should be multidisciplinary and multimodal (32).
Laser therapy of the trigonal region may be a specific treatment. Kaur and Trunkalaivonan have concluded that “treatment at its best” is by behavioural therapy including biofeedback, meditations, bladder retraining and hypnosis has been used with some success (31).
1. Engeler D, Baranowski AP, Elneil S, et al: Guidelines on Chronic Pelvic Pain 2012
2. Padmore DE, Norman RW, Millard OH. Analyes of indications for and outcome of epididymectomy. J Urol. 1996 Jul;156(1):95-6.
3. Nickel JC, Siemens DR, Nickel KR, et al. The patient with chronic epididymitis: characterization of an enigmatic syndrome. J Urol.2002 Apr;167(4):1701-4.
4. Rab M, Ebmer AJ, Dellon AL. Anatomic variability of the ilioinguinal and genitofemoral nerve:implications for the treatment of groin pain. Plast Reconstr Surg 2001 Nov; 108(6):1618-23.
5. Eklund A, Montgomery A, Bergkvist L, et al. Chronic pain 5 years after randomized comparison of laparoscopic and Lichtenstein inguinal hernia repair. Br J Surg. 2010 Apr;97(4):600-8.
6. Heidenreich A, Olbert P, Engelmann UH. Management of chronic testalgia by microsurgical testicular denervation. Eur Urol.2002 Apr;41(4):392-7.
7. Sweeney P, Tan J, Butler MR, et al. Epididymectomy in the management of intrascrotal disease: a critical reappraisal. Br J Urol. 1998 May; 81(5):753-5.
8. Nariculam J, Minhas S, Adeniyi A, et al. A review of the efficacy of surgical treatment for and pathological changes in patients with chronic scrotal pain. BJU Int 2007 May;99(5):1091-3.
9. Alfieri S, Amid PK, Campanelli G, et al. International guidelines fro prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia.2011 Jun;15(3):239-49.
10. Andersson B, Hallén M, Leveau P, et al. Year:2004. Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: a prospective randomized controlled trialSurgery 5: 464-72.
11. Wright D, Paterson C, Scott N, et al. Five-year follow-up of patients undergoing laparoscopic or open groin hernia repair: A randomized controlled trial. Ann Surg. 2002 Mar;235(3):333-7.
12. Hallén M, Bergenfelz A, Westerdhal J. Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: long-term follow-up of randomized controlled trial.Surgery.2008 Mar;143(3):313-7.
13. Van Haarst EP, van Andel G, Rijcken TH, et al. Value of diagnostic ultrasound in patients with chronicscrotal pain and normal findings on clinical examination. Urology 1999 Dec; 54(6):1068-72.
14. Lau MW, Taylor PM, Payne SR. The indications for scrotal ultrasound. Br J Radiol. 1999 Sep;72(861):833-7.
15. Strebel RT, Leippold T, Luginbuehl T, et al. Chronic scrotal pain syndrome: management among urologists in Switzerland.Eur Urol. 2005 Jun;47(6):812-6.
16. Messelink EJ. The pelvic pain centre. World J Urol 2001 Jun; 19(3):208-12.
17. Cornel EB, van Haarst EP, Schaarsberg RW, et al. The effect of biofeedback physical therapy in men with Chronic Pelvic Pain Syndrome Type III. Eur Urol 2005 May;47(5):607-11.
18. Hetrick DC, Glazer H, Liu YW, et al. Pelvic floor electromyography in men with chronic pelvic pain syndrome: a case-control study. Neurourol Urodyn 2006;25(1):46-9.
19. Rowe E, Smith C, Laverick L, et al. A prospective, randomized, placebo controlled, double-blind study of pelvic electromagnetic therapy for the treatment of chronic pelvic pain syndrome with 1 year follow-up. J Urol 2005 Jun;173(6):2044-7.
20. Anderson RU, Wise D, Sawyer T, et al. Integration of myofascial trigger point release and paradoxicalrelaxation training treatment of chronic pelvic pain in men. J Urol 2005 Jul;174(1):155-60.
21. Srinivasan AK, Kaye JD, Moldwin R. Myofascial dysfunction associated with chronic pelvic floor pain: management strategies. Curr Pain Headache Rep 2007 Oct;11(5):359-64.
22. Strom KH, Levine LA. Microsurgical denervation of the spermatic cord for chronic orchialgia: long-term results from a single center. J Urol.2008 Sep;180(3):949-53.
23. Levine LA, Matkov TG. Microsurgical denervation of the spermatic cord as primary surgical treatment of chronic orchialgia. J Urol.2001 Jun;165(6 Pt 1):1927-9.
24. Heidenreich A, Olbert P, Engelmann UH. Management of chronic testalgia by microsurgical testiculardenervation. Eur Urol 2002 Apr;41(4):392-7.
25. Cadeddu JA, Bishoff JT, Chan DY, et al. Laparoscopic testicular denervatiuon for chronic orchalgia. J Urol. 1999 Sep;162(3 Pt 1):733-5: discussion 735-6.
26. Granitsiotis P, Kirk D. Chronic testicular pain: an overview. Eur Urol 2004 Apr;45(4):430-6.
27. Sweeney CA, Oades GM, et al. Does surgery have a role in management of chronic intrascrotal pain? Urology.2008 Jun;71(6):1099-102.
28. Calleary JG, Masood J, Hill JT. Chronic epididymitis: is epididymectomy a valid surgical treatment? Int J Androl. 2009 Oct;32(5):468-72.
29. Parsons CL, Zupkas P, Parsons JK. Intravesical potassium sensitivity in patients with interstitialcystitis and urethral syndrome. Urology 2001 Mar;57(3:428-32; discussion 432-3.
30. Parsons CL. The role of a leaky epithelium and potassium in the generation of bladder symptoms in interstitial cystitis/overactive bladder, urethral syndrome, prostatitis and gynecological chronic pelvic pain. BJU Int. 2011 Feb;107(3):370-5.
31. Kaur H, Arunkalaivanan AS. Urethral pain syndrome and its management. Obstet Gynecol Surv 2007 May;62(5):348-51; quiz 353-4.
32. Yoon SM, Jung JK, Lee SB, et al. Treatment of female urethral syndrome refractory to antibiotics. Yonsei Med J. 2002 Oct;43(5):644-51.
Correspondence:Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576