Andrew Siegel MD 3/7/2018
New Jersey is shut down because of the impending Nor’easter, surgery and office hours are cancelled, so I have plenty of free time and am going to post this entry today rather than on Saturday morning.
Orchialgia is medical-speak for chronic testes (ball) pain, defined as constant or intermittent pain perceived in the testicles, lasting for 3 or more months and interfering with one’s quality of life. It is a not uncommon problem of men of all ages, but is more frequently seen in young adults. It certainly keeps us busy in the office…some morning sessions seem like “ball clinics”!
Testes 101
Image above, public domain from Wikipedia
The testes are paired, oval-shaped organs that are housed in the scrotal sac. They have two functions, testosterone and sperm production. Encased within the tough and protective cover of the testes (tunica albuginea) are 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.
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.
The scrotal sac has several roles, packaging the testes as well as aiding 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.
Good news/bad news:
The good news about the testes location dangling between one’s legs is is ready and easy access for examination, unlike the female counterpart (ovaries), which are within the abdomen. This is one reason why testes cancer is so much easier to diagnose at an early stage than ovarian cancer.
The bad news is that their precarious location dangling between one’s legs as well as their delicate packaging in the thin sac makes them subject to trauma and injury.
Chronic orchialgia
Chronic testes pain can be caused by numerous different conditions and it is 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.
Evaluation
The evaluation of the patient with chronic testes pain includes a detailed history, a careful examination of the scrotal contents, groin and prostate, if necessary, as well as a urinalysis and possibly urine culture. It is helpful to obtain an ultrasound of the scrotum, a study which utilizes sound waves to image the testicle and epididymis. On occasion, it is warranted to obtain imaging studies of the upper urinary tract and pelvis and possibly a CT or MRI of the spine if there is back or hip pain.
Management
The management of chronic testis 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.
Wishing you the best of health,
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Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery. Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.
Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health
Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health
Tags: Andrew Siegel MD, chronic ball pain, Chronic testes pain, male pelvic fitness, orchialgia, pain, spermatic cord denervation, testes, testicles, urology
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