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Urology/testicular pain

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QUESTION: the problem is I have had this right testicular pain for months now. The ultrasound was normal and the doctor will only offer me painkillers and says the pain i have is normal.

From what i have read about chronic epididimitis it is a long term if not permanent condition so i feel like i am stuck with this permanently. It is beginning to really make me depressed. It has robbed me of libido completely and now i am left with constant but low level pain and discomfort both day and night. Taking baths seems to be making it worse lately.

I have been patiently waiting to see if it goes away. What are the chances of this given that it has already been 3-4 months now?

is there absolutely anything more i can do on my own? perhaps try supplements specifically aimed at the prostate and sexual health?

ANSWER: Jim:

Unfortunately, it is unlikely the pain will disappear or resolve by itself at this point.  You should consult a urologist to see if a surgical exploration or epididymectomy might be considered.  Essentially, we take a careful look at the testicle surgically and much of the time we find small cysts or scarring that might cause the pain.  If everything else fails, we can remove the whole testicle.

There really isn't much you can do on your own.

---------- FOLLOW-UP ----------

QUESTION: on what basis do you say it is unlikely to disappear?

does the fact that the pain does vary in intensity and in characteristic tell you any more about the causes or whether it will go away?

About 3 weeks ago, the pain gradually started to lessen. The testicle started to feel normal. I was encouraged by this and thought it might even finally go away. This improvement lasted about a week. But then it got worse again and I'm back to where i was. what does this tell you?

where is the evidence that removing the testicle or epididymis will resolve the pain?

if you do a surgical exploration you will be cutting the scrotum open. This in itself can cause pain after the surgery. As you know hernia operations can actually cause permanent pain.

why do you dismiss herbal supplements?

and what are urologists such as yourself doing to cure chronic epididymytis? Its far easier to remove testicles and other parts than to find a real cure but this is not the answer. We need a better understanding of what is causing the pain. What is causing inflammation in the absence of any infection. How it can be that healthy young men can suddenly be affected by this terrible condition.

why dont you think i should have another ultrasound or other non invasive examination first? Is it not true that a good ultrasound technician will be able to pickup all problems in the testicle far better than a visual examination by surgical exploration?

ANSWER: Jim:

The variability in the intensity does nothing to identify the cause or predict outcome.  My suggestion that the pain is not likely to go away has to do with my 30 years of experience in similar cases and the long duration (months) that you indicated.  An infection would have recovered in that time.

Surgery on the scrotum causes only minimal skin pain temporarily and this is mild and quickly disappears.  This is not the same as the pain after hernia surgery which may involve nerve entrapment.

Removing the testicle does not necessarily get rid of the pain.  Microsurgical denervation of the spermatic cord can often help and does not require testicle removal.  

We dismiss herbal supplements because there is no good scientific evidence that they work and even if they did the industry is not regulated so you can't be sure of what is actually in the supplement capsules and tablets.

What do we do to cure epididymitis?  We use antibiotics and anti-inflammatories.  The issue is not that epididymitis is not cured, but that there is scar tissue or other damage done that causes the pain afterwards.  We would be happy to do more research on this if there was funding available but the limited research funding we have typically goes to urological cancer issues.

Repeating the ultrasound is not unreasonable and gives you a chance for a comparison with the previous, but experience has shown me that it rarely helps much.

It is definitely NOT true that ultrasound shows more lesions or problems than a surgical exploration.  Ultrasound can look into the testis better, but ultrasound is limited in the size of lesions that it can identify.  Anything smaller than 1/2 cm (about 1/4 inch) will not show up well with ultrasound.

I've posted a few references for you to review that may help a little.





Chin Med J (Engl). 2012 Aug;125(15):2784-6.
Microsurgical denervation of the spermatic cord for treatment of idiopathic chronic orchialgia.
Tu XA, Gao Y, Zhang YD, Zhuang JT, Zhao JQ, Zhao LY, Zhao L, Sun XZ, Qiu SP, Deng CH.

Eur Urol. 2004 Apr;45(4):430-6.
Chronic testicular pain: an overview.
Granitsiotis P, Kirk D.
Author information Department of Urology, Glasgow Royal Infirmary, 16 Alexandra Parade, Glasgow G31 2ER, UK. voula@btinternet.com
Abstract
Chronic testicular pain (orchialgia, orchidynia or chronic scrotal pain) is common and well recognized but its pathophysiology is poorly understood. Currently treatment is largely empirical. This article aims to present an overview of its prevalence, possible aetiology and the available treatment options. The contribution of psychological factors is unclear, although some of these patients undoubtedly are depressed. Post vasectomy chronic testicular pain may be due to functional obstruction of the vas, or to spermatic granuloma. The surgical technique used may be relevant and the application of intraoperative local anaesthetic may have a role in reducing the risk. The importance of the sympathetic nervous system and the role of a possible alteration of the adrenergic receptors of the vas deferens in patients with chronic testicular pain are discussed. For patients failing to respond to conservative treatment, microsurgical denervation of the spermatic cord, epididymectomy and vasovasostomy have all shown a degree of relief. Unfortunately a small number of patients fail to respond to both conservative and more invasive treatment methods and for them the only available therapeutic option is inguinal orchiectomy.

J Urol. 1990 May;143(5):936-9.
Analysis and management of chronic testicular pain.
Davis BE, Noble MJ, Weigel JW, Foret JD, Mebust WK.
Author information Department of Surgery, University of Kansas Medical Center, Kansas City.
Abstract
A total of 45 patients was seen in consultation between May 1980 and April 1989 for chronic unilateral or bilateral orchialgia, defined as intermittent or constant testicular pain 3 months or longer in duration that significantly interferes with the daily activities of the patient so as to prompt him to seek medical attention. We analyzed 34 patients available for followup in terms of socioeconomic parameters, etiology and duration of pain, associated urological symptomatology, specific treatment and results of therapy. Of the patients 31 underwent surgical treatment after failing medical management (24 orchiectomies, 10 epididymectomies, 5 orchiopexies and 1 hydrocelectomy). Of 10 patients who underwent epididymectomy 9 underwent subsequent orchiectomy as definitive treatment. Of 15 patients who underwent inguinal orchiectomy 11 (73%) reported complete relief of pain, while 4 had partial relief. Of the 9 patients who underwent scrotal orchiectomy 5 (55%) reported complete relief of pain, 3 had partial relief and 1 denied improvement. On the basis of these results we recommend inguinal orchiectomy as the procedure of choice for the management of chronic testicular pain when conservative measures are unsuccessful.






---------- FOLLOW-UP ----------

QUESTION: the problem is a lot of the advice you give is in contradiction to what mainstream research indicates. You say that based on your 30 years, testicular pain is permanent. However the research indicates that it does eventually burn out. It does go away but it can return. and you go onto to say the infection would have cleared up by now. However in chronic epididimitis there is no infection causing the inflammation, by definition. The references you cite state that it is a poorly understood condition. I would say that is an understatement. What do you understand about it?

Both papers recommend orchietomy and ignores the dangers, risks and disadvantages of such practices. In addition you dismiss both herbal and non herbal remedies which does have scientific research.

The question is are you willing to admit that doctors and urologists are failing us?

Its not just a lack of funding that is the issue. The issue is modern day medicine is failing us. There are more and more incurable chronic diseases which are affecting many people and less breakthroughs and cures.
More and more doctors are ignorant about the link between healthy diet and disease because they do not receive the training.

Often the patients do not have an opportunity or the right to question the doctors or voice their views so I will use this as a rare opportunity so that you may inform your fellow colleagues that medicine is failing us.

The standard of healthcare is diminishing while the doctors providing it are getting increasing salaries.

Answer
Jim:

This will be my final response to you on this topic.

I didn't say your testicular pain was permanent, only that it was "unlikely the pain will disappear or resolve by itself at this point" and this was based on your description of it lasting for months.  I stand by that statement.

Chronic testicular pain remains a poorly understood condition where we can do all sorts of tests and treatments and still fail to identify a source of the pain or adequately treat it in all cases.  

The papers I cited do include information risks and side effects from surgery but the purpose of the papers was to indicate to physicians the available treatment options and were not intended for patient use.  The first article reviews microsurgical denervation of the spermatic cord which is something less than an orchiectomy and both papers recommend surgery only when alternatives have failed.

We dismissed herbal remedies because of the lack of "peer reviewed scientific studies" and the fact that even if a reliable herbal remedy was found it would be hard to prescribe.  Many so-called effective remedies for a variety of illnesses and disorders have been found to actually contain prescription medications which explains their efficacy.  If you wish to try an herbal remedy before resorting to a surgery, fine but you do so at your own risk as herbal supplements are not regulated and the contents are therefore uncertified.

There is abundant medical information about diet and various aspects of health and new information comes out every day.  Some of the information is conflicting or contradictory.  The only way to know for sure is to do a proper double-blinded prospective study involving enough people and following their progress long enough to find out for sure what really works and what doesn't.  Such studies are rare and quite expensive to do.  Most of the published research on herbal supplements do not meet this standard, are not published in peer-reviewed journals and do not reach scientific validity or statistical significance.  Until we can be sure about a product or drug, we tend not to recommend it.

If you think medicine is failing you, that may be your opinion and it may even be true.  We can only offer the best advice available based on solid evidence.  I'm sorry if that information and advice is not acceptable to you.

I would disagree that healthcare standards are diminishing.  We are making new discoveries and breakthroughs every day; too numerous to mention here but let me give you an example. During my training, the standard treatment for kidney stones was a big open surgical procedure to cut open the body and urinary tract to remove the stone.  Today, this is almost never done as we can remove such stones with lithotripsy machines, special scopes and lasers.  

As far as increasing salaries, my income and that of many of my colleagues has been decreasing.

I wish you good luck with your testicular pain.  

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Stephen W. Leslie, MD

Expertise

Questions concerning erectile dysfunction, kidney stones and prostate disorders including prostate cancer. I have a special interest in kidney stone disease prevention.

Experience

Full time practicing urologist with 30 years experience. Associate Professor of Surgery and Chief of Urology at Creighton University Medical Center. Editor in Chief of eMedicine Urology internet textbook. Author of only NIH approved book written for patients by a urologist on the subject of kidney stones "The Kidney Stones Handbook". Inventor of the "Parachute" and "Escape" kidney stone baskets and the "Calculus" stone prevention analysis computer program.

Organizations
American Urological Association, Ohio State Medical Association, Sexual Medicine Society

Publications
Men's Health, Journal of Urology, Urology, Healthwatch Magazine, Emergency Medicine Monthly, eMedicine, "The Kidney Stones Handbook", and numerous articles in various newspapers. He is also the editor of the Urology Board Review by McGraw-Hill used by urologists to study for their Board Certification Examinations.

Education/Credentials
Graduate of New York Medical College with residencies completed at Metropolitan Hospital New York, Albany Medical Center and University of Wisconsin-Madison.

Awards and Honors
Thirlby Award of the American Urological Association. Rated as one the country's Best Urologists by the Independent Consumer's Research Institute

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