ll pain: solving mysteries of the male scrotum · on the docket • good –hydrocele –epididymal...
TRANSCRIPT
ll Pain: Solving mysteries of the male scrotum
@DrAshBowen
On the Docket
• Good– Hydrocele
– Epididymal cysts
– Varicocele
• Bad– Testis Cancer/Tumor
– Epididymitis/Orchitis
– STI
– Torsion
• UGLY– Chronic Orchalgia
– Post Vas Syndrome
– Spousal Revenge Syndrome
Objectives
• Describe conditions that may produce scrotal pain
• Determine which scrotal conditions require emergent surgery
• Form an accurate differential diagnosis for scrotal pain
• Establish a pathway for the treatment of chronic orchalgia
Disclosures
I DO NOT want to be the ball pain king of Oklahoma
I DO NOT have any financial conflicts of interest.
Hydrocele
• Cause• Differential• To US, or not to US• Treatment
– Surgery– Drain/sclerose
• Cause
• Differential
• To US, or not to US
• Treatment – Surgery– Drain/sclerose
Epididymal Head Cyst (Spermatocele)
• Exam
• Reassurance
• Diff Dx
• Surgery only if bother• Reassurance• 17% risk of obstruction
with removal
Varicocele
• 15% of all males– 10% with pain,
• Si/Sx– Pain– Infertility– Hypogonadism
• Surgery• Outcomes
– 2.8x more likely to get pregnant
– 60-90% pain relief– Improvement in Testosterone
levels
The Red Herrings
• Nephrolithiasis
• Appendicitis
• Back pain, Lumbar disc herniation
• Neuropathy
Epididymitis/Orchitis
• DO NOT GIVE CIPRO• DO give NSAIDs• Rule out torsion• CDC Guidelines
– <35 yo Ceftriaxone 250mg IM &/or Doxy 100mg bid x10d
– ≥35 yo Levofloxacin or Oflaxacin x 10 days (add ceftriaxone in MSM
• 4-6 weeks may be needed for chronic epidiymitis
Vaccines Cause Adults
• Mumps Orchitis
– Sudden onset orchalgia, swelling
– Abdominal pain, nausea & vomiting
– Preceded by parotitis
– Supportive treatment
Testicular Torsion• Generalized testicular
pain & absence of cremasteric reflex
• Other: Nausea 10-60%, scrotal swelling late
• Associated with rest or activity
• Decreased Reliability of CDUS– Sensitivity 63-90%
Torsion Continued…
• Outcomes
– Risk of Orchiectomy
• 5% at 0-6 hrs
• 80% at 24 hrs
• 75% of “saved” testes will atrophy if >24hrs
Fournier’s Gangrene
• When to walk…– Fever, chills, malaise
– Erythema, swelling, pain, warmth
• When to run…– Fetid odor
– Necrosis
– Pain out of proportion to exam
– Air
Chronic Orchalgia
• ~5% of Urology patients
• 18% may never get satisfactory explanation
– 40% may be idiopathic
• History and Physical are key
– What antibiotics?
– Rectal exam, pelvic floor
UPOINT
First Line Treatment
• NSAIDs
– Meloxicam 7.5-15mg daily
– Ibuprofen 600mg TID
• Antibiotics
– 4-6 weeks
– Appropriate medication
• <35 doxy, >35 levaquin
Pelvic Floor Physical Therapy
• Can be curative in up to 80%– Neuromuscular re-
education (EMG, Biofeedback)
– Manual therapy (Soft tissue mobilization, Myofascial release, Connective tissue mobilization)
2nd Line Treatment
• Tricyclic Antidepressants
– 27% Major depression, 56% somatization disorder
– Amytriptyline 10-25mg daily
– Nortriptyline 10-150mg daily
• Lyrica/Gabapentin
– Gabapentin 300mg TID
– Pregabalin 50mg TID
Cord Block and Trigger Point
Surgical Therapies
• Microscopic Cord Denervation
– At 6 mo, 86% improved, 52% pain free
• Epididymectomy
– Complete response 10%, Partial response 88-90%
• Orchiectomy
– Decreased pain in 40-75%
Calixte et al. CurrUrol Rep. 2017.
Strohm et al. J Urol. 2008.
Epididymectomy
Hinman et al. Atlas of Urologic Surgery, 2nd Ed.
Microscopic Cord Denervation
When all else fails…
• Spinal cord stimulation
– In-office test
– 86% improved
– VAS from 7.6 to 2.4
– Small series
• Cord cryoablation
– 70% improved, 5% resolved
• Scrotox
– 62% improved, 7.5% resolved
#SQ788 • Canadian Meta-analysis, 169 pts with neuropathic pain, 6 trials
• All trials showed statistically significant decrease in pain, longest trial 8 weeks
• Only 3 of 6 showed clinically significant improvement (2pts on 10 pt VAS, 30% improvement)
• Safe, well tolerated
Deshpande et al. Can FamPhysician 2015
Post Vas Pain • 15% early after vasectomy
– <1% beyond 6 months
• Start with NSAIDs, scrotal support, ice/heat
• Surgical Efficacy
– Excision of granuloma
– Epididymectomy ~50%
– Vas reversal ~69%
– Nerve ligation 75-85%
– Orchiectomy 55% scrotal, 73% inguinal
Spousal Revenge Syndrome
• Occurs in men who have some type of sexual encounter outside of committed relationship
• Symptoms of STD
– Work up negative
• 100% pelvic floor spasm
– Treat with PFPT
• May also occur in female spouse after husband admits infidelity
Pediatric Scrotology
• Rule out torsion
• Epididymitis
– If pyuria antibiotics, if UA normal supportive management
– If post-pubertal, low threshold to treat for GC/Chlamydia
• Perinatal torsion
• Torsion of the Appendix Testis
Pediatric Scrotology Cont…
• Henoch-Sch ሷ𝑜nlein purpura
– Scrotal findings in 2-38%
• Edema, erythema, hematoma, torsion, epididymitis
• Choose Wisely
– Don’t routinely order US on boys with cryptorchidism
Conclusions
• You can do a lot with out an ultrasound, use your fingersound
• You can make a big difference in men with chronic orchalgia before they see a urologist
• Don’t fear the scrotum
• Get an Ultrasound on kids with acute scrotal pain
