CURRENT ICS DEFINITION
Scrotal pain may or may not be localised, for example to the testis, epididymis, cord structures or scrotal skin.
July 2017
Dr. Markos Karavitakis

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Taxonomy: 1. Lower Urinary Tract Symptoms (LUTS), 1.6 Genital and Lower Urinary Tract Pain
and
Scrotal pain syndrome is the occurrence of persistent or recurrent episodic scrotal pain which is associated with symptoms suggestive of urinary tract or sexual dysfunction. There is no proven epididimo-orchitis or other obvious pathology.
Taxonomy: 1. Lower Urinary Tract Symptoms (LUTS), 1.7 Genito-Urinary Pain Syndromes and Symptom Syndromes Suggestive of LUTD.
These definitions derive from the Standardisation of Terminology of Lower Urinary Tract Function: Report from the Standardisation Sub-committee of the International Continence Society. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, Van Kerrebroeck P, Victor A, Wein A. Neurourol Urodyn 2002;21:167-78. (see Abrams et al. 2002).

Scrotum is a small, fibro- muscular and cutaneous sac underneath the penis. It contains three important structures of the male reproductive systems:
  • Testis which are responsible for the production of sperm cells and the male sex hormone testosterone
  • Epidydimis which connects the testicle with the vas deferens
  • Vas deferens which delivers sperm into the urethra during ejaculation
The dartos and cremaster muscle are also present in the scrotal sac. Both work in conjunction to regulate the temperature of the testis. The scrotum also contains blood vessels (anterior and posterior scrotal and testicular arteries and veins), nerves (genital branch of genitofemoral nerve, anterior and posterior scrotal nerves and perineal branches of posterior femoral cutaneous nerve) and lymphatics.
Scrotal pain can be the presenting symptom of a wide range of surgical and non-surgical conditions and can be a challenging and frustrating experience for both patients and professionals.
Scrotal pain should be distinguished on the basis of etiology or tissue origin of pain as primary or referred if actually originates from somewhere else in the groin or the abdomen and is felt in the scrotum. It should aslo be distignuised on the basis of duration as acute, subacute and chronic if occurs for at least 3 months.
Causes of scrotal pain include:
  • TESTICULAR TORSION
    • Relative frequent cause of acute scrotal pain, occurring in 1/4000 males under 25 years old, though is more frequent between 12-16 years old
    • Refers to the twisting of the spermatic cord within the scrotum leading to firstly venous and later arterial flow obstruction and subsequent testicular necrosis and atrophy
    • Diagnosis is main clinical based on symptoms such as severe acute scrotal pain
    • General symptoms such as nausea and vomiting might also be present
    • Signs such as swelling of the scrotum, “high riding testis” ie elevated testis due to shortening of the cord, abnormal position of the testis within the scrotum (transverse position) and absence of cremasteric reflex
    • Doppler ultrasound can also be used to confirm reduction or absence of blood flow. However, a normal ultrasound examination might not exclude testicular torsion
    • Testicular torsion is a real emergency requiring immediate surgical treatment with scrotal exploration, detorsion and bilateral orchidopexy
    • Manual detorsion in a clockwise direction in the left side and counterclockwise in the right side, can also be considered in cases where operative intervention is not possible

  • TORSION OF EMBRYONIC REMNANTS
    • Most commonly affects the appendix testis, also called hydatid cyst of Morgagni
    • Most frequently occur in children between 10 and 12 years old
    • Compare to testicular torsion, symptoms in the torsion of embryonic remnant is more gradual in onset, of longer duration and less severe
    • Typically, there is discrete localized tenderness in the upper pole of the testis which is not tender and lies normally in the scrotum
    • Diagnosis is mainly clinical
    • Doppler ultrasuonography may confirm the good testicular circulation
    • In case of doubt exploration of the scrotum is required
    • Treatment is conservative

  • EPIDIDYMITIS
    • Acute epididymitis is a clinical syndrome consisting of pain, inflammation and swelling of the epididymis that lasts <6weeks
    • When symptoms last for more than six weeks, is called chronic epididymitis
    • When testis is also involved, it is called epidydimal-orchitis
    • Most frequent causes of epididymitis in sexually active men is C.Trachomatis and N. Gonorrhea
    • Non-sexually transmitted causes of acute epididymitis include bacteriuria secondary to bladder outlet obstruction, urinary tract instrumentation or surgery, immunosuppression, systemic diseases etc
    • Chronic epididymitis is most commonly related to granulomatous reaction such as mycobacterium tuberculosis
    • Most common symptoms include testicular pain, tenderness and swelling
    • Hydrocele is also frequently seen
    • Microscopic examination of urethral secretion or first void urine are the preferred laboratory tests for the diagnosis
    • Treatment aim to microbiologic cure of infection with antibiotics such as ceftriaxone, doxycycline and ofloxacin. improvement of symptoms mainly with anti-inflammatory medication

  • VARICOCELE
    • Varicocele is an abnormal dilatation of the pampiniform venous plexus of the scrotum
    • It is a frequent condition affecting 10 to 20% of the general population
    • Defective valves in the veins is considered the main cause of varicoceles
    • Dilatation of testicular vein lead to increased testicular temperature and accumulation of toxin agents which in turn might have a negative impact on production of spermatozoa and cause male infertility
    • Varicocele can sometimes be a cause of scrotal aches, discomfort, dull pain and throbbing sensations
    • Pain usually get worse after walking or standing for a long time due to higher hydrostatic pressure within the valves
    • Varicoceles are easily identified as the classic “bag of warms” on palpation
    • Doppler sonography is used to confirm the diagnosis by demonstrating venous dilation and reflux
    • Varicoceles are classified in grades
      • Grade 0: non-palpable, subclinical ultrasound
      • Grade I: palpable during a Valsava maneuver
      • Grade II: visible in the standing position during a Valsava maneuver
      • Grade III: visible in the standing position without Valsava maneuver
    • Whenever indicated treatment of varicocele is surgical with microsurgical varicocelectomy be considered as the gold standard

  • CHRONIC ORCHIALGIA
    • Chronic testicular pain (orchialgia) is a complex urogenital focal pain syndrome which is defined as intermittent or constant testicular pain for a period of 3 months or more which interferes with daily activities
    • Pain can involve any of the scrotal content including the testicle, epididymis, paratesticular structure and spermatic cord
    • Etiology of chronic orchialgia is idiopathic and remains unknown. Secondary causes of chronic orchialgia might include post-vasectomy pain syndrome, trauma, inguinal herniorrhaphy and epididymitis
    • Upregulation of pain transmission pathways is one of the main pathophysiological mechanism underlying the development of this syndrome
    • Chronic orchialgia is primarily a diagnosis of exclusion requiring great attention on the history and physical examination
    • Imaging and laboratory tests can be used to identify or rule out conditions such as infection, malignancy etc.
    • Treatment options for chronic orchialgia might include
      • Non-steroid anti-inflammatory drugs
      • Antibiotics such as quinolones and doxycycline
      • Antidepressants as amitriptyline
      • Anticonvulsant gabapeptin
      • Psychological counseling
      • Pulsed radiofrequency to denervated the spermatic cord
      • Surgical treatment includes epididymectomy, vasovasostomy and vasectomy reversal for postvasectomy cases, orchiectomy, laparoscopic testicular denervation, and microsurgical denervation of the spermatic cord








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