What Causes Chronic Testicular Pain?
Orchialgia is the medical term for chronic testicular pain, defined as constant or intermittent pain in the testicles, lasting for three or more months and interfering with one’s quality of life. It’s not an uncommon problem for men of all ages, but it is seen more frequently in young adults. It certainly keeps us busy in the office…some morning sessions seem like “ball clinics”!
What do the testes do?
The testes are paired, oval-shaped organs that are housed in the scrotal sac. They have two functions, testosterone and sperm production. The tough, protective cover of the testes (tunica albuginea) encase tiny tubes called seminiferous tubules which make sperm cells. The testes also contain specialized cells called Leydig cells that produce testosterone. Sperm from the testes travels to the epididymis for storage and maturation. The epididymis empties into the vas deferens, which conducts sperm to the ejaculatory ducts.
Where are the testes located?
The testes are suspended in the scrotal sac via the spermatic cord, a “rope” of tissue containing connective tissue, the vas deferens, the testes arteries, veins, lymphatics, and nerves. The spermatic cord is enveloped by tissues that are extensions of the connective tissue coverings of three of the abdominal core muscles. The most important of these coverings surrounding the spermatic cord is the cremaster muscle, which elevates the testes in a northern direction when it contracts.
What does the scrotal sac do?
The scrotal sac has several functions. The scrotal sac houses the testes and aids in their function by regulating their temperature. For optimal sperm production, the testes need to be a few degrees cooler than core temperature. The dartos muscle within the scrotal wall relaxes or contracts depending on the ambient temperature, allowing the testes to elevate or descend to help maintain this optimal temperature. Under conditions of cold exposure, the dartos contracts, causing the scrotal skin to wrinkle and to bring the testicles closer to the body. When exposed to heat, dartos relaxation allows the testicles to descend and the scrotal skin to smoothen.
What causes chronic testicular pain?
Chronic testicular pain can be caused by numerous conditions, and it’s important to rule out the following possibilities:
- Infection: An infection of the testes (orchitis), epididymis (epididymitis), both (epididymo-orchitis), or the spermatic cord (funiculitis). Infections can be bacterial, viral, and at times inflammatory without an actual infection.
- Tumor: A benign or malignant mass of the testes or epididymis.
- Groin hernia: A prolapse of intra-abdominal contents through a weakness in the connective tissue support of the groin.
- Torsion: A twist of the testes or one of the testes or epididymal appendages.
- Hydrocele: An excess fluid collection in the sac surrounding the testes.
- Spermatocele: A cyst resulting from a blockage of one of the sperm ducts within the epididymis.
- Varicocele: Varicose veins of the spermatic cord.
- Trauma: Injury.
- Prior operations: Groin hernias are most commonly associated with chronic testes pain; less commonly, vasectomies and any other type of groin or pelvic surgery.
- Referred pain: Pain perceived in the testes, but originating elsewhere, e.g., a kidney stone that has dropped into the ureter, or a lower spine issue affecting the nerves to the testes.
- Tendonitis: There are numerous muscles with tendons that insert into the pubic bone region that can be subject to injury and inflammation.
- Pelvic floor muscle tension myalgia: Excessive muscle tension in these muscles can cause pelvic pain, including pain in the testes.
- Idiopathic: This fancy medical term means that we are clueless about the origin of the pain. Unfortunately, many men have idiopathic orchialgia, a distressing and frustrating experience for both patient and urologist.
The evaluation of the patient with chronic testicular pain includes a detailed medical history and a careful examination of the scrotal contents, groin, and prostate, if necessary. A urinalysis and urine culture will also be taken. It’s also helpful to obtain an ultrasound of the scrotum, a study which utilizes sound waves to image the testicle and epididymis. On occasion, it’s warranted to obtain imaging studies of the upper urinary tract and pelvis, as well as a CT or MRI of the spine if there is back or hip pain.
Can chronic testicular pain be treated?
The management of chronic testicular pain is directed at the underlying cause, although unfortunately this cannot always be precisely determined. Often, a course of antibiotics may prove helpful even if the physical findings are indeterminate. Anti-inflammatory medications such as Advil and ibuprofen are often useful in the short-term management. Supportive, elastic jockey shorts as well as local application of a heating pad can be helpful. At times, amitriptyline or Neurontin can be helpful for neurologically-derived pain. If the source of the pain is felt to be tension myalgia, referral to a pelvic floor physical therapist can be beneficial. A referral to a pain specialist, typically an anesthesiologist who focuses on this discipline, can be advantageous.
An injection of a local anesthetic into the spermatic cord (spermatic cord block) can be a useful diagnostic test and a means of alleviating the pain. If spermatic cord block proves successful in relieving the pain, it may be necessary to surgically denervate the spermatic cord, a procedure in which the nerve fibers in the spermatic cord are divided. Under extremely rare circumstances, removal of the epididymis or the testicle is necessary. Often chronic testis pain remains elusive with the source undetermined and is thought to be similar to other chronic inflammatory conditions.