Highlight risks and benefits and provide realistic expectations of short- and long-term postsurgical outcomes. It is also important to address psychological factors and social stressors that often contribute to chronic pelvic pain syndromes, which can improve long-term outcomes regardless of the chosen treatment. For this reason, a referral to a psychiatrist may be indicated.
Microsurgical denervation of the spermatic cord. Removal of the afferent nerve stimulus to the testicle is believed to result in the downregulation of the peripheral and central nervous systems, so the patient no longer has the perception of testicular pain. Several small trials have yielded favorable symptomatic pain relief scores in up to 71% of patients, with reported adverse outcomes including rare testicular atrophy—but no complaints of hypoesthesia or hyperesthesia of the scrotum, penile shaft, inguinal, or medial thigh skin.21,22 This treatment should be considered only in patients who have experienced a significant degree of temporary relief from spermatic cord injection.
Epididymectomy is recommended only when pain is localized to the epididymis, as this is a testicle-sparing procedure. Unilateral or bilateral epididymectomy is a viable option for the treatment of chronic orchialgia related to postvasectomy pain syndrome or chronic epididymitis. Reports highlighting symptomatic improvement based on small case series range from 43% to 74%, with the highest success rate found during a 5½-year follow-up.23-25 In 1 study, 90% of patients reported that they were satisfied with their choice to undergo the procedure.25
Vasectomy reversal (vasovasostomy) and inguinal or scrotal orchiectomy should be considered only after all other treatment modalities have failed. Vasovasostomy has the potential to restore fertility in up to 98% of cases,26 which may or may not be desirable. One study of men who experienced post-vasectomy pain syndrome and underwent microsurgical vasovasostomy found that after nearly 2½ years, 84% experienced complete pain resolution.27
The goal of orchiectomy is to relieve orchialgia by releasing the entrapped ipsilateral genitofemoral and/or ilioinguinal nerves. One study determined that 90% of men who underwent unilateral epididymectomy for chronic orchialgia required an orchiectomy to resolve pain.1 Another study found that 80% of patients continued to suffer both short- and long-term debilitating orchialgia postorchiectomy.28
CASE 2 Jason H
Jason saw a urologist, who initially offered him bilateral spermatic cord blocks. They provided Jason with moderate symptom relief on most days of the week and allowed him to increase his physical and sexual activities. Three months later, Jason went back to the urologist for evaluation because he felt that the effects of the spermatic cord blocks had worn off. In the next 6 months, he had 2 additional bilateral blocks.
Nearly a year after a series of spermatic cord blocks, most of it spent in persistent discomfort, Jason returned to his FP with a request for narcotic pain medication. The FP tried to be supportive, but told Jason that chronic narcotic therapy was not an ideal choice—and referred him back to the urologist to discuss surgical options.
The urologist recommended a bilateral epididymectomy and the patient, who was desperate to obtain some pain relief and now regretted undergoing a vasectomy, agreed. Within the first few weeks after his surgery, he noticed a reduction in pain, and he slowly increased his physical activity. A year later, Jason reported only minimal testicular and scrotal discomfort that did not limit his physical or sexual activities—and he continues to be pleased with the outcome of his treatment.
CORRESPONDENCE Joel J. Heidelbaugh, MD, FAAFP, Ypsilanti Health Center, 200 Arnet, Suite 200, Ypsilanti, MI 48198; jheidel@umich.edu