Testicular Pain – Not Always What it Seems: A Cross-sectional Assessment of Patients Presenting for Chronic Scrotal Content Pain at a Tertiary Care Center

Abstract

ABSTRACT Introduction Introduction:: Chronic scrotal content pain (CSCP) is generally defined by persistent and bothersome pain present for > 3-months. This symptom complex leads to frustration for patients and providers alike, as the underlying etiology varies and in many instances is unknown. Scrotal pain may arise from outside the scrotal contents, as is seen with musculoskeletal conditions involving the hips, lower back, and pelvic musculature. Identifying those patients who have signs or symptoms of a musculoskeletal etiology earlier in their clinical course will allow for a more streamlined treatment pathway and minimize the need for unnecessary referrals. Objective To review historical and examination findings in patients presenting to a tertiary care center for evaluation of chronic testicular pain. Methods We reviewed our clinical experience with referrals for surgical intervention for “chronic testicular pain” at a tertiary care medical center between July 2019 and October 2020. Prior to scheduling an appointment, patients are queried via a list of questions to gather additional information in order to determine whether specialist consultation is indicated. Pertinent information was collected including historical patient data, physical examination findings, laboratory and imaging results, and treatment as recommended by the assessing physician. In addition, we gathered data on the number of prior consults and interventions performed by outside clinicians. The data was summarized to present a cross-sectional representation of patients presenting for CSCP. Results In total, 126 patients were seen for a primary chief complaint of CSCP. Mean patient age was 45 years [standard deviation (SD) 15]. 31 (24%), 55 (44%), and 40 (32%) were self-referred or referred by their primary care provider or a urologist, respectively. 88 patients (70%) had seen at least one prior urologist. 22/126 (17%) reported bilateral testicular pain. 29 patients (24%) had undergone a prior unsuccessful surgical intervention for their pain. On examination, reproducible testicular tenderness was present in only 57 patients (45%), despite 109 patients (87%) stating testicular pain as their primary chief complaint. Digital rectal examination of the pelvic floor musculature was positive for tenderness in 31/126 patients (25%), suggesting a possible pelvic floor contribution. After thorough assessment, musculoskeletal etiologies were suspected to underlie CSCP in 49 patients (39%), prompting additional evaluation and/or referrals. This included 35 patients (28%) who were specifically referred to a pelvic floor physical therapy specialist. Surgery was recommended in 68/126 patients (54%), including microdenervation of the spermatic cord in 22% (after successful diagnostic spermatic cord block), and epididymectomy in 13%. Conclusions CSCP presents with a wide array of concurrent symptoms. The history and physical examination must include assessments for concurrent abdominal, back, hip, and other genital/pelvic pain that may lend towards an alternative non-urologic treatment pathway. Disclosure No