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Urology/Hypertonic Cremasteric muscle

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QUESTION: 65 yo. I had an LRP in 2008 for prostate cancer, PSA remains <0.04. I remain incontinent and relatively impotent post procedure but still am very sexually active. The problem: After orgasm, my right testicle retracts so significantly that it feels like a rupture. Successive orgasms within 24 hours exacerbates the pain so that 2 or more almost cripple me for 24 hours. The pain then becomes significant in my whole lower abdomen affecting bowel movements. If I wait for 3 or more days between orgasms, there can be little or no discomfort. Left testicle does not retract as I had left inguinal hernia repair in 1995 and it never retracts. There is a significant palpable vas deferns on right side but all tests (mri and CT with contrast) show is “enlarged blood vessels on right side and testicle rides high”.  I have been to Duke (recommended denervation of right testicle), Cleveland Clinic (no recommendation never heard of the problem) and my local urologist (only recommendation is to try orchioplexy). As a last resort, I have been thinking of going to a general surgeon (GP recommendation) to see about severing the cremasteric muscle. Thoughts?

ANSWER: John:

Nobody has more respect for general surgeons than I do, but surgery on the spermatic cord and testicle should be done by a urologist.  A surgical procedure on the testicle will probably help.  The testicle can be separated from the bulk of the cremasteric fibers and replaced in the scrotum which should fix the problem.  The testicle is being pulled tightly into the external ring.  Since it doesn't fit, it hurts when the pulling continues.  If the spermatic cord is "skeletonized" so that all unnecessary fibers are removed, it will not be drawn up and the pain should stop.

Of course, nothing is guaranteed but that should help.

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

QUESTION: Your answer sounds very reasonable. Since I have consulted urologists locally, at Duke and the Cleveland Clinic and since none of them have mentioned this as a possible treatment, are there centers where this procedure can be performed by anyone with experience? Thanks.

Answer
John:

I'm very surprized that you didn't get a similar answer at the major centers you've described.  I would try another local urologist. You can also come here to Creighton University Medical Center where I practice but you should be able to get some help locally.

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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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