an overview of chronic scrotal pain and its most common causes

1. Overview of
Chronic Scrotal Pain
Hassan Almarzooq

2. Why This Topic?
• Limitations to daily activities.
• Limited ability to work and sexual dysfunction.
• Psychological disorders, depression, somatization disorder.
• Social isolation.
• Decreased quality of life.

3. Definition
• intermittent or constant, unilateral or bilateral
• localized to the scrotal structures
• 3 months or longer in duration
• significantly interferes with daily activities
• and prompts the patient to seek medical attention.

4. ETIOLOGY
• 50% of patients will not have an identifiable etiology.
• “self-palpation” orchitis.
• Psychological.

5. Varicocele
• Dilatation of the pampiniform plexus of spermatic vein.
• Clinical features:
• Asymptomatic.
• Dull, aching, scrotal pain. standing Vs recumbency position.
• Scrotal fullness.
• Large, soft, left-sided? scrotal mass ( bag of worm).
• Infertility.
• Alarming features:
• Unilateral right varicoceles. (IVC)
• Non-diminishing.

6. Management
Up to date

7. Hydrocele
• collection of peritoneal fluid between the parietal and
visceral layers of the tunica vaginalis.
• Idiopathic Vs Reactive.
• Clinical features:
• Painless swelling.
• Heaviness.
• Pain (correlate with size).
• Transilluminates.
• Treat: symptomatic, skin integrity is compromised.
• Management:
• excision of the hydrocele, Simple aspiration?

8. Epididymal cyst/Spermatocele
• Round soft mass in the head of the epididymis.
• Main differential: epididymal cystadenoma or, rarely, cystadenocarcinoma Examination: as
a “cluster of grapes”. US
• Clinical features:
• Painless swelling.
• Heaviness.
• Pain (correlate with size).
• Transilluminates.
• Surgical excision. If chronic pain.

9. Testicular cancer
• Painless, firm, nontender nodule or mass that does not transilluminate.
• +- gynecomastia, elevated Beta- hCG
• Scrotal ultrasound is the diagnostic test of choice to evaluate a testicular nodule or mass.
• MRI if US inconclusive.
• AFP, beta-hCG. normal serum values do not exclude testicular cancer.

10. DIAGNOSIS - CSP
• History
- Pain: SOCRATE
- Urinary, Sexual and Bowel functions.
- Hx of: scrotal, inguinal, abdominal or pelvic surgeries. PVPS
- history of psychological, physical or sexual abuse.
• PE:
- scrotal structures: concentrating on the testis, epididymides and vasa for any
anatomic abnormalities and to localization.
- scars, hernias or areas of tenderness.
- PR; Tone, tenderness, enlargement.
- Neurological examination of the lower limbs for sensory deficits and radiculopathy.

11. Diagnosis
• Lab: Hx and PE directed
• lower urinary tract symptoms or hematuria; Urine analysis.
• Urethral discharge, or penile pain; gonorrhea and chlamydia.
• Palpable abnormality/ mass; Scrotal ultrasound
• routine scrotal ultrasound is debated.
• Spermatic cord blockade is used as a diagnostic and therapeutic measure.

12. TREATMENT
• Conservative therapies.
• watchful waiting.
• scrotal support.
• heat or cold therapy.
• avoidance of aggravating activities.
• Psychological therapy & CBT.
• catastrophic thinking.
• irrational fear of injury.
• pain distorted thinking.
• Medical management
• NSAIDs.
• Antibiotics.
• Tricyclic antidepressants.
• Neuropathic Medications.

16. Reference
• Diagnosis and Management of Chronic Scrotal Pain, (AUA)
https://drive.google.com/file/d/1-q44O1SFjMK2OoefMK3rSf96L9-55-
xW/view
• Nonacute scrotal conditions in adults, (UTD)

17. Thank you