Diagnosis and Treatment of Chronic Testicular Pain

The testicle and spermatic cord are common places to suffer chronic and sometimes debilitating pain. Some of the causes of chronic testicular and spermatic cord pain are trauma, infection and neurologic disease. The pain itself can range from just annoying to completely debilitating. After seeing many patients with chronic testicular and cord pain, we have developed a protocol for treatment of these issues.

In deciding how to treat this chronic pain, it is important to distinguish between “local” and “central” pain. As pain exists in any body part for a long time, the brain begins to think of all stimulation and feeling from that area as being painful. This can result from old trauma, infection, or neurologic problems such as diabetic neuropathy. Sometimes, as in the case of an infection, even if the infection is completely gone, the pain may persist. Similarly, even if the painful part is removed, the pain may continue. The classic example of this is the diabetic with a foot that needs to be amputated but even after the amputation the patient still has “foot pain”. This “phantom” pain is because the nerves coming from the foot going to the brain have become jumbled such that the patient perceives constant pain in a foot that is no longer there.

In chronic scrotal and testicular pain, typical causes are a history of vasectomy, a history of epididymitis or orchitis, or previous surgery on the testicle. In deciding how best to treat this pain, it is essential to differentiate between local and central pain. Most commonly we do this with an injection of a local anesthetic and steroid into the spermatic cord in the area of the groin where the patient feels pain. If this temporarily relieves the pain, this indicates that the origin of the pain is in the spermatic cord rather than the brain. A patient who has testicular pain coming from the spermatic cord may be a candidate for a microscopic denervation of the cord, also knows as neurolysis or microscopic neurolysis of the spermatic cord.

Microsurgical Denervation of the Spermatic Cord

Microscopic denervation of the spermatic cord is done in the operating room with a small incision in the groin, such as where a hernia repair is done. If a hernia repair was already done, we go through the previous scar. The spermatic cord contains arteries, nerves, the vas deferens and lymphatic vessels. During surgery, these are isolated and we slowly dissect out all of its components in order to preserve the testicular artery and several lymphatic channels. We do with the use of a microsurgical Doppler probe. If the patient is interested in fertility, we also keep the vas deferens intact. If not, we divide the vas deferens and its associated structures. All of the other structures are divided and then the “skeletonized” cord (i.e. the artery and lymphatics) is put back in the normal anatomic position. The incision is then closed with absorbable sutures so there is nothing to remove. Typically, the entire procedure takes 1-2 hours. The patient may return home or to a hotel that night.

In properly selected patients, we have had excellent results, with over 90% of patients achieving between 70-100% of pain resolution.