Consider a tricyclic antidepressant or gabapentin
Both tricyclic antidepressants (TCAs) and gabapentin have demonstrated benefit in the treatment of chronic pelvic and neuropathic pain.8,9 Doses should be titrated to achieve a maximal therapeutic benefit while avoiding anticholinergic and neurologic side effects.
A cohort study using a multidisciplinary team consisting of a psychologist, an anesthetist, a physiotherapist, and an occupational therapist found >50% symptomatic improvement in 62% of men with chronic orchialgia treated with gabapentin up to 1800 mg per day, and 67% of men treated with nortriptyline up to 150 mg per day.10
However, a subgroup of patients who reported postvasectomy testicular pain did not achieve a 50% symptomatic improvement rate with either TCA or gabapentin therapy.
CASE 1 Vincent B
The FP reassured Vincent that his physical examination was normal and recommended a 1-month trial of ibuprofen (600 mg every 6 hours), and regular use of supportive briefs. Since the patient had been treated with antibiotics in the past with no change in symptoms—and because he was thought to be at low risk for an STI—the physician did not prescribe another empiric trial of antibiotics. He did send the patient for an ultrasound evaluation of the scrotum and testes, which revealed only a 0.5 × 0.4 × 0.6-cm right epididymal cyst that was not palpable on examination.
The patient returned after 1 month, noting that his symptoms had neither improved nor worsened. The FP suggested that he stop taking the ibuprofen and begin a trial of gabapentin 100 mg daily, titrating up to 3 times daily for the first month, then to 300 mg 3 times daily in the second month.
When he returned 3 months later, Vincent reported that his symptoms had improved by about 50%. He has since been able to increase both the intensity and frequency of physical activity. Vincent is not interested in further increasing the dose of gabapentin and declined a referral to a urologist for consideration of procedural and surgical therapeutic options, but agreed to follow up as needed if his testicular pain worsened.
Postvasectomy pain is not unusual
Several years after a vasectomy, the diameter of a man’s ejaculatory ducts often doubles in size to counteract the increase in fluid pressure.11 The specific cause of long-term post-vasectomy pain syndrome, or congestive epididymitis, is unknown, but has been reported in 5% to 43% of men who have undergone this procedure.12-14 Sperm granulomas or spermatoceles represent the body’s effort to spare the testicle from damage secondary to increasing fluid pressure. While these granulomas are benign lesions, their presence may predispose a man to postvasectomy pain syndrome.15-17
CASE 2 Jason H
Two months before Jason’s visit to the FP, his testicular pain had become so excrutiating that he went to the ED seeking treatment. He was given an ultrasound with color Doppler and found to have postvasectomy surgical changes consistent with bilateral spermatoceles, but no evidence of epididymitis or a mass. Before leaving the ED, Jason received ceftriaxone (125 mg IM) as gonorrhea prophylaxis. He was discharged home with prophylactic antibiotics for chlamydia, as well as ibuprofen. He was advised to avoid strenuous physical activity and told to follow-up with his FP if his symptoms did not improve.
During several months of conservative medical therapy, including trials of NSAIDs, quinolone antibiotics, TCAs, and gabapentin, Jason did not experience any significant pain relief. He was frustrated by the dull, aching pain in his scrotum that continued to limit his physical and sexual activities.
Finally, the FP recommended a urologic consultation.
Consider these minimally invasive procedures
When conservative medical management fails, minimally invasive techniques are the next step. There are 2 commonly used procedures, both of which can be performed by a urologist in an outpatient setting.
Spermatic cord blocks with lidocaine and methylprednisolone have been shown to provide relief for weeks up to several months in small case studies, and may be repeated at intervals of several months if modest relief is achieved.18,19
Transrectal ultrasound-guided periprostatic anesthetic injections, another microinvasive option, offers minimal risk and may provide some short-term relief. However, data on long-term benefit and resolution of pain and disability are lacking.20
Consider surgery only after all else fails
If all medical and conservative therapies have been tried and the patient continues to have debilitating pain, surgical options should be considered. Because current surgical therapies are not always effective and are not reversible (and research on the various options is limited), it is important to initiate a detailed discussion with the patient. Such conversations should be held in consultation with a urologist.