BackTable / Urology / Article
Testicular Pain Treatment: Medical, Surgical & Musculoskeletal Approaches
Devante Delbrune • Nov 4, 2022 • 36 hits
The management of testicular pain-related diagnoses remains complex for both patients and physicians. Patients often have difficulty discussing these issues with their physician or healthcare professional, and even when they do, the healthcare provider must navigate the challenges of determining safe and appropriate treatment options.
Dr. Brahmbhatt and Dr. Silva discuss the various treatment methods for testicular pain on the BackTable Urology Podcast, including surgical, medical, and musculoskeletal approaches. Dr. Brahmbhatt also provides detailed insight into his testicular pain treatment algorithm. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable Urology Brief
• Medical management of testicular pain should target underlying pathologies. This is often accomplished by prescribing anti-inflammatories like Mobic and antibiotics like Bactrim.
• Muscle relaxants are commonly prescribed for testicular pain. However, these medications should not be used as first-line treatment due to their addictive properties.
• Spermatic cord anesthesia block (SCAB) is a go-to procedure for testicular pain treatment. This is a nerve block procedure that typically utilizes a combination of anesthetics, such as Exparel and Marcaine, along with a separate steroid infusion such as Decadron to manage inflammation.
• Alternative approaches like physical therapy, yoga, weight loss and acupuncture may also be effective in treating testicular pain.
Table of Contents
(1) Medical Management of Testicular Pain
(2) Procedural Interventions For Testicular Pain
(3) Musculoskeletal Approaches to Testicular Pain
Medical Management of Testicular Pain
To begin the evaluation of patients with testicular pain, urologists are advised to take a thorough patient history, conduct an in-depth physical exam, and order appropriate imaging such as a CAT scan or scrotal ultrasound. It is important to discuss what the patient hopes to gain from treatment and what medications they have been utilizing for pain control. Although it may seem controversial, Dr. Brahmbhatt is a firm believer in not prescribing or refilling pain medication unless they relate to a surgery he is performing. Prescribed medication should target the underlying etiology as opposed to just symptom management.
First-line treatment for the management of testicular pain is usually anti-inflammatory drugs. A 7.5 mg dose of Mobic may be prescribed for patients with moderate pain, while a Medrol Dosepak may be utilized for patients with severe pain. These medication regimens will often be accompanied with a dose of antibiotics such as Bactrim. Dr. Brahmbhatt prefers Bactrim over other antibiotics as it avoids potential drug-drug interactions between alternative antibiotics, Mobic, and Medrol. While antibiotic resistance is prevalent in medicine, antibiotics are indicated in this case as they effectively treat the underlying inflammation (e.g prostatitis). When it comes to medical management of testicular pain, urologists should be open to trying different medications and working with other healthcare professionals who may be better versed in medical management of inflammation and pain. Ultimately, it is important to approach patients suffering from chronic testicular pain with an open mind and utilize a team-based approach, as testicular pain is a multi-faceted, complex condition with diverse differentials.
[Jamin Brahmbhatt MD]
So I usually like Meloxicam Mobic, and they can always take ibuprofen as well, but Meloxicam Mobic is a lot. I think it has a much better safety profile. So 7.5 is a very mild dose, so it goes up to 15 milligrams. So I usually just put them on Mobic 7.5 and I tell them, “Hey, if you're taking any other anti-inflammatory, you can stop it. What I will do for some of my most severe patients is actually put them on a Medrol Dosepak. The first time I meet them, like, okay, this is what we're gonna do. We're gonna try to attack everything as best we can as if you're coming to the emergency room with a broken back, you know, we're gonna say you have a broken ball. So I'll start them on a Medrol Dosepak. I'll start them on Meloxicam and plus or minus antibiotics. Now this is a little bit controversial, because antibiotics we know, are more for infections, but, you know, knowing our patients with prostatitis and other things like, sometimes giving them a short course of it. As if it's prostatitis or some kind of itis. I think it does help influence the inflammatory process. And I know there's a lot of research going on on this topic. I don't always prescribe antibiotics, especially since one of the most common ones we prescribe has a black box warning. But, usually it's some kind of postal steroids, if they're severe, when they come see me and then, we'll try that Meloxicam.
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Procedural Interventions For Testicular Pain
When medical management is ineffective following 30-90 days of treatment, urologists may turn to nerve block and surgical intervention. Dr. Brahmbhatt mentions two main procedural options in the treatment of testicular pain patients. The first of these procedures is a spermatic cord anesthesia block (SCAB), also known as a nerve block. This is often utilized first if the patient wishes to avoid surgery or is not a strong candidate for surgical intervention. Preferred anesthetic agents include Exparel and Marcaine, with an infusion of Decadron for its anti-inflammatory effect. Follow-up is recommended 5-7 days after the intervention in order to determine the efficacy of treatment.
The second procedural option for those that do not have effective nerve block results is neurolysis. Neurolysis works by dividing the nerves in the spermatic cord. Dr. Brahmbhatt prefers to utilize robotic surgery when performing spermatic neurolysis. He does note, however, that a microscopic approach can be utilized, and the available data reports no difference between the two approaches in terms of efficacy of treatment.
[Jamin Brahmbhatt MD]
So our patients often have a lot of pain and they've had a lot of PTSD. So we do our blocks under some kind of sedation, whether it's nitrous oxide in our office, or if they want to go completely asleep, that's fine. Now it may seem a little extreme. But a lot of our patients we've looked back at, a lot of their PTSD has come from just an exam or like an injection or trauma or some sort. But you could also do it with the patient awake if they're comfortable doing it. I do do a fair share now just in the office, especially when they're traveling, it's hard to coordinate everything, but regardless of the sedation tactic. A spermatic cord block, essentially. First of all, what do we mix? So every block is different. When I'm doing it, when I have the availability of having something like Expearl, which is a long acting anesthetic, we'll mix Exparel with Marcaine, that's all I'll inject. The biggest mistake people make out there is they inject too little. So what I've learned from our experiences. You want to inject a lot of this stuff in there because you want to get it as deep into the crevices and to the small areas as best you can.
When you're just injecting like five CC’s or six CC’s , it's not going to go anywhere. So most of our blocks are 30 CC’s in volume, and obviously the mixture can change based on where I am or what the patient wants and can afford to do. But, my preference is Exparel and Marcaine, but if it's in the office where you want to be a bit more cost-effective, then you can use Lidocaine and Marcaine at the same time. But the key is we often infuse four milligrams of Decadron, a steroid in there. So you get an enhanced anti-inflammatory effect when we're doing the block. So all of our cocktails have about 30 CCS and we mix some long acting, something short acting, and then we add the steroid in there. The block. It's hard to describe verbally here. But essentially, and, this may kind of make some people like crevice here. But you want to get as high up into the cord as you can. So you want to be able to get right where the cord comes out of the inguinal canal. That's what we do is, we take a lot of the scrotal skin and then we put our finger all the way up where we can feel the canal. And then I keep my finger right on the canal and I protect the cord underneath my hands. And then I basically go to the right and the left of the patient. And that's, if they're having general pain, now, what I will do, and this is more for their psychosocial addition. I also ask where your pain is the most so if they think it's a specific spot in the skin or near a cyst. I'll keep five CC’s of it and inject it directly. So they feel like it's going there. And it may have been of some benefit to them too, because what if, what I've injected on top, doesn't get all the way down there.
But that's basic. It takes under a minute to do. and then depending on where I've done it, how I've done it, where they're from. I'll either follow up with them in five days or seven days. So I'll give it some time. I'm not going to call them the next day or the day afterwards, but usually at a week, I'll give them a phone call and it's usually a no charge phone call. Like I know my God urology, no charge. I mean, obviously if the insurance allows it, but it's usually a very quick phone call cause I've already prepped them up for okay. If it works, it's this pathway, but it hasn't worked it’s this pathway.
I’ve got some guys that are like high level, either professional athletes or executives that I just do a block on them as needed. Like maybe once a year, like they have a flare up. But then if they're looking for something more definitive then our next go-to is generally something called neurolysis. So neurolysis, the way I describe to patients is kind of like a nerve dividing or nerve stripping. But for us, it's essentially knowing the anatomy of the cord and knowing where those nerves are and kind of like getting in dividing that tissue. So you're basically cutting off the signal to the testicle.
Musculoskeletal Approaches to Testicular Pain
Medical and surgical approaches may be ineffective or infeasible for certain patients experiencing testicular pain. In these patients, it is pertinent to determine the pathology of the testicular pain through imaging such as MRI. If the imaging indicates a musculoskeletal pathology, Dr. Brahmbhatt recommends alternative treatment options aptly dubbed “musculoskeletal approaches.” Some of these treatment recommendations include physical therapy, yoga, weight loss, and even acupuncture.
When utilizing any of these therapeutic approaches, Dr. Brahmbhatt emphasizes the importance of identifying partners (e.g. physical therapists) that have expertise in testicular pain. This expertise is required for referred pain pathology such as chronic groin pain. Many providers may not fully understand the condition, which leads to improper prescription of medication. A primary example of this is Flexeril, a commonly prescribed muscle relaxant. Dr. Brahmbhatt states that while patients may benefit from a short-term prescription of the medication, muscle relaxants are associated with a high risk of addiction. For this reason, he does not personally prescribe or recommend muscle relaxants as first-line treatment in patients with a musculoskeletal origin of pathology.
[Jamin Brahmbhatt MD]
So you bring up a great question. I'm glad you did, because people are going to think I'm just knife happy here. So all of our patients, whether we're seeing them naive or are seeing some other people and they haven't had things, then we maximize everything medical. So antibiotics, if we think it's some kind of infectious process or anti-inflammatories for at least 30 days to 90 days, in combination with something else, if it's, if we think it's more nerve related. If it's muscular or even if I don't think it's muscular, I do tell all our patients. Hey, listen, we can do physical therapy.
The problem with physical therapy. You need someone that's like an expert and some places don't have experts in that field. Like if you kind of watch how the therapy's done on the groin, it may seem like an X-rated film sometimes, but it's a very professional professional therapy that's done. And yes, there's tons of research that shows it's effective. I recommend that. I recommend acupuncture to these patients. I recommend stress therapy, yoga, and weight loss if they're overweight. So yes, we definitely go through all these things as best we can. Cause it's not chronic until it's at least three months, but even if it's been past three months and there's certain things that haven't been tried, we absolutely will try them beforehand. But in my experience, stuff like that doesn't work as well. And maybe it's just, I just see the worst of the worst when it comes to these.
So you mentioned when does musculoskeletal come into play? What's really awesome is I think it was a couple of years ago. There was some abstract or something that talked about the use of MRI and I've actually integrated MRI into a lot of my workup now as well. So what do I do because I've talked to the doctors that manage the teams here in central Florida, like what do you do for your athletes? How do you look at musculoskeletal things? I talked to the radiologist about what's the best form of imaging. It's actually very easy. We already ordered an MRI of the prostate. Those are essentially MRI pelvises, but it's essentially an MRI of the pelvis and all you have to do to get it done right is just put MSK. MSK rates, a musculoskeletal read. So there's a certain way. I still don't understand this. That's why I'm not a radiologist, but there's a way to do the scanning and looking where they look at a lot of things. So we asked, we found ligament issues and tears, and we found microfractures. And so in those patients, you know, then it takes a team approach. So if I find a hernia, we consult one of the general surgeons like, hey, can we do something together? Or you fix the hernia first when it's something like this. I send them to whatever the issue may be as a specialist in that to have the patient evaluated. But they usually come back to us afterwards.
Dr. Jamin Brahmbhatt
Dr. Jamin Brahmbhatt is the director of urology and robotic microsurgery at the Orlando Health Medical Group Urology PUR Clinic in Florida.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2022, July 27). Ep. 47 – Management of Chronic Testicular Pain [Audio podcast]. Retrieved from https://www.backtable.com
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