Microsurgical Treatment Of Chronic Testicular Pain
Chronic testicular pain may be associated with different etiologies such as trauma, infection, hydrocele, varicocele, testicular tumor, vasectomy. Almost 25% of these cases are of unknown origin. Initial course of action is usually nonsurgical including antibiotics, analgesics, anti-inflammatory medications and regional nerve blocks. When conservative treatment failed, next course of therapy is unclear. Such radical treatment of testicular pain as inguinal orchiectomy was successful in 76% of patients but in one study did not relieve pain in up to 80% of patients.
If temporary spermatic cord block is successful in relieving chronic testicular pain, the next treatment option, surgical denervation of the spermatic cord, should be considered strongly. Since testicular pain may arise from scrotal and spermatic branches of genitofemoral and ilioinguinal nerves, it is possible to relieve the pain by the division of these fibers.
The goal of complete microsurgical denervation of the spermatic cord is to divide all nerve fibers, somatic and autonomic, traveling with the spermatic cord. The procedure is performed under the operating microscope via the subinguinal (varicocelectomy) incision at the level of the external inguinal ring. The inguinal nerve is identified as it exited the external inguinal ring and divided. Then spermatic cord is elevated on Penrose drain and usual microsurgical varicocelectomy procedure is performed. Additionally all fascial and cremasteric fibers are transected so at the end only testicular artery, vas deferens and vasal vessels, lymphatic channels remained intact.
Potential complications include testicular atrophy, hydrocele, hypoethesia of the scrotum, penile shaft, inguinal or medial thigh skin , and persistent testicular pain. Careful selection of patients with the understanding that results will not be universally satisfactory is mandatory.
The postvasectomy pain syndrome represents very specific cause of chronic testicular pain. The incidence of pain in the testis and epididymis is about 3-8%. The etiology is unknown with commonly cited causes as dilatation of epididymal tubule, inflammation, perineural fibrosis, sperm extravasation or yet unidentified process.
The conservative treatment of postvasectomy pain syndrome is usually successful and includes sitz baths, scrotal support, antibiotics, NSAID, spermatic cord block. A variety of the treatment procedures have been used in patients after failed conservative treatment. They ranged from excision of sperm granuloma, open-end vasectomy, and microsurgical epididymectomy and microsurgical vasectomy reversal to orchiectomy. In one study 27 of 32 men with postvasectomy pain syndrome had resolution of pain after vasectomy reversal. The disadvantage of this procedure, obviously, may be restoration of fertility.
Varicocele ligation for the treatment of pain is controversial. The incidence of pain in men with varicocele is 2-10%. The most common complaint of these patients is a dull throbbing pain that worsens with straining and exercise. Treatment of painful varicocele traditionally consists of conservative measures followed by surgery. Conservative efforts include scrotal support, anti-inflammatory medications and limitation in physical activity. Surgical treatment of painful varicocele is successful when performed in a highly selected population of men who have specific pain complaints and in whom conservative treatment failed. Limited studies found pain resolution in 48-86% of patients operated for painful varicocele
1.Myers SA, Mershon CE, Fuchs EF. Vasectomy reversal for treatment of the post-vasectomy pain syndrome. J Urol 1997; 157:518-520
2. Devine CJ, Jr., Schellhammer PF. The use of microsurgical denervation of the spermatic cord for orchialgia. Transaction of the American Association of Genito-Urinary Surgeons 1979;70:149-151
3. Choa RG, Swami KS. Testicular denervation. A new surgical procedure for intractable testicular pain. Br J Urol 1992;70:417-419
4. Levine LA, Matkov TG, Lubenow TR. Microsurgical denervation of the spermatic cord: a surgical alternative in the treatment of chronic orchialgia.