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Keywords:

  • chronic scrotal pain;
  • epididymectomy;
  • orchidectomy;
  • histopathological changes

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

OBJECTIVES

To assess the efficacy of surgical treatment for chronic scrotal pain (CSP) and to examine histopathological changes in epididymectomy and orchidectomy specimens in these patients.

PATIENTS AND METHODS

CSP is a rare condition that for some patients can be severely debilitating. Although first-line treatment is conservative and includes the use of analgesics, many patients still complain of persistent pain. Nerve denervation and spermatic cord block might be attempted, but often patients proceed to surgery. The clinical notes of 26 patients (mean age 49 years) who had surgery for CSP were analysed retrospectively. Data included: the duration of pain before presentation, investigations before treatment, risk factors for CSP, initial conservative management, pain team referral, history of previous scrotal surgery and clinical outcome. All pathological specimens were examined to identify any changes in the epididymis and testis.

RESULTS

In 16 patients (62%), the pain resolved completely after surgery, but the other 10, despite showing an improvement, had residual pain. Histopathological examination of epididymectomy specimens revealed changes associated with obstruction, including sperm extravasation, tubule distension and focal fibrosis. All testis specimens had a variable degree of tubular sclerosis and chronic inflammation, with nine showing extensive infarction, suggestive of previous episodes of infection or ischaemia.

CONCLUSION

In this review, 62% of patients had complete resolution of pain and the remainder had a partial response after surgical treatment for CSP. All specimens showed pathological changes in the epididymis or testis, with changes suggestive of recurrent episodes of ischaemia or infection. The results show that CSP can be successfully treated surgically in many cases where conservative methods fail to provide symptomatic relief.


Abbreviations
CSP

chronic scrotal pain.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Chronic scrotal pain (CSP) poses a special challenge for the urologist. It is difficult to treat, as the cause is often unknown, and might require a multidisciplinary approach. In many patients, the clinical examination is often normal and investigations such as scrotal ultrasonography and microbiological urine analysis can be unremarkable. It is defined as ‘a continuous or intermittent pain that can be unilateral or bilateral and lasts for a minimum of three months’[1]. The pain is often severe enough to affect the daily activities of the patient, causing them to seek medical help.

There are many possible causes of CSP. Pain might be caused primarily by pathology in the scrotum or groin, or be referred from another area (‘referred pain’). Local causes can include chronic infection of the testis or epididymis, testicular tumour, indirect inguinal hernia, hydrocele, spermatocele or varicocele. Referred pain might originate from the ureter (ureteric stone), prostate (chronic prostatitis) or lumbar spine (degenerative lesions). A subset of patients present with CSP after vasectomy. Ahmed et al.[2] found that 19% of patients complained of scrotal discomfort after vasectomy and 5% reported pain lasting for >3 months. However, in up to 25% of cases no identifiable cause for CSP is found, despite extensive investigation [1].

Investigation of CSP can include scrotal, renal and transrectal ultrasonography, and plain X-rays. Initial treatment is conservative and consists of analgesia, a trial of antibiotics and α-blockers [3]. If the pain persists, other forms of management, including referral to the pain team for spermatic cord block and nerve denervation, might be considered [4].

Only when conservative management fails are patients considered for surgery, involving either an initial epididymectomy (which might be followed by orchidectomy if pain persists) or radical inguinal orchidectomy in the first instance. However, patients are warned that surgery might not resolve their symptoms. The aim of this review was to assess the efficacy of surgical treatment for CSP and to examine surgical specimens from these patients for pathological changes.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

A series of 26 consecutive patients who had surgery for CSP at one institution over 10 years (between 1996 and 2006) was identified. All met the clinical criterion of CSP lasting ≥3 months. The following clinical information was gathered retrospectively: age at presentation, duration of pain before referral, previous scrotal surgery and any radiological investigations before treatment. Information about the initial conservative treatment was also recorded. Finally, the efficacy of surgical treatment was assessed on the basis of improvement or complete resolution of pain.

The surgical treatment consisted of either a staged procedure in which epididymectomy was performed initially, followed by orchidectomy if the pain was unresolved, or a radical inguinal orchidectomy in the first instance, through a groin incision. All haematoxylin and eosin-stained sections (cut at 3 µm) from the surgical specimens of these 26 patients were reviewed by a urological pathologist, and pathological changes in either the testis or epididymis were noted.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

The mean (range) age of the 26 patients was 49 (22–78) years and their mean duration of pain was 36 (3–72) months; the mean follow-up was 35 (1–72) months. Of the 26 patients, 13 (50%) had had previous scrotal surgery, including vasectomy in eight and varicocele repair in five; in the other 13 there were no risk factors for the pain.

All 26 patients were initially prescribed analgesia, a trial of antibiotics and α-blockers. The α-blocker commonly used was alfuzosin (Xatral XL; Sanofi-Synthelabo) for 3 months. If pain persisted, all patients were offered referral to the pain team for either spermatic cord block or nerve denervation; six elected to have spermatic cord block and five to have nerve denervation. Nerve denervation for CSP consists of dividing all the nerve fibres, somatic and autonomic, travelling with the spermatic cord. Despite these treatments, the pain persisted in all patients.

The surgery for CSP was as follows: epididymectomy alone in three patients, which led to complete resolution of their pain; epididymectomy followed by inguinal orchidectomy in eight; or a radical inguinal orchidectomy in the first instance in 15.

In 16 (62%) patients (including five who had had a vasectomy and three who had had varicocele repairs), the pain completely resolved after surgery, and they needed no further treatment. However, pain persisted in the other 10 patients, although there was some improvement in symptoms (Table 1).

Table 1.  The management and outcome of the 26 patients with CSP. All the patients had received initial conservative treatment before surgery consisting of analgesia, antibiotic and α-blocker treatment
Patient numberND/SCBEpid onlyEpid/orchidRIOPrevious SSPain resolved
  1. ND, Nerve denervation; SCB, spermatic cord block; Epid, epididymectomy; orchid, orchidectomy; RIO, radical inguinal orchidectomy; SS, scrotal surgery.

1YesYesYesNo
2YesYesNo
3YesYesYes
4YesYesYesNo
5YesYesYes
6YesYesYesYes
7YesYes
8YesYesYes
9YesYesYes
10YesNo
11YesYesNo
12YesNo
13YesYesYes
14YesYesNo
15YesYesYes
16YesNo
17No
18Yes
19YesYesYesYes
20YesYesYesYes
21YesYesYes
22YesYesYes
23YesYes
24YesYesYes
25YesYesYes
26YesYesNo
Total1138151316 Yes

The surgical specimens showed pathological changes in all cases. Of the 11 initial epididymectomy specimens, nine showed epididymal tubule distension, sperm extravasation and chronic inflammation (Fig. 1a,b). The other two epididymal specimens showed focal fibrosis. All 23 testis specimens showed pathological changes, with tubular sclerosis and chronic inflammation in 14 cases (Fig. 1c) and infarction in the other nine (Fig. 1d).

image

Figure 1. a , Sperm extravasation; high-power view (× 400) of a sperm granuloma in an epididymectomy specimen. b, Epididymal distension; normal epididymal tubules (top left) with dilated tubules containing sperm (bottom right). c, Testicular seminiferous tubules showing focal sclerosis. A few residual tubules showing spermatogenesis are seen (top left). d, An area of the testis showing infarction and focal microcalcification.

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DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

CSP poses many problems for the urologist in terms of what treatment regimen to use and if surgery should be used. There are a few papers reporting that surgery for CSP does not always provide symptomatic relief, particularly if the pain is referred from other organs, i.e. the prostate, ureter or lumbar spine [1,3].

In the present study, 16 of 26 patients (62%) had complete resolution of pain after surgery. The other 10 patients reported a slight improvement but still had persistent pain. Interestingly, in 13 patients (50%) the onset of CSP was after previous scrotal surgery (vasectomy, varicocele repair), suggesting that this might be a risk factor for CSP. This hypothesis is supported by Ahmed et al.[2] who reported that CSP was a long-term complication of vasectomy in 5% of patients in their study. Given this, it might be advisable to discuss CSP as an uncommon complication when obtaining consent from patients for vasectomy.

To our knowledge, there are few reports of pathological changes in surgical specimens from patients with CSP, and these mainly examined changes after vasectomy [5,6]. All patients in the present study had pathological abnormalities in either the testis or epididymis, including features suggestive of previous obstruction, ischaemia or inflammation. These changes might result from episodes of intermittent torsion or retrovasal reflux of urine, suggesting that these factors might relate the pathological changes to the symptoms experienced.

In summary, surgery is a valid option for patients with CSP for whom conservative methods fail to resolve symptoms, and will continue to be offered at our hospital. However, patients should be advised that scrotal surgery might not always lead to resolution of pain. The pathological changes in the resected specimens are suggestive of recurrent episodes of ischaemia or infection and these might be contributory factors in patients with CSP.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES