BackTable / Urology / Podcast / Transcript #47

Podcast Transcript: Management of Chronic Testicular Pain

with Dr. Jamin Brahmbhatt

In this episode of BackTable Urology, Dr. Jose Silva and Dr. Jamin Brahmbhatt discuss the evaluation, causes, and treatment of chronic testicular pain. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Difficulty Seeking Care For Testicular Pain

(2) Initial Evaluation for Testicular Pain

(3) Referred Pain in Patients Seeking Urological Evaluation

(4) Nerve Block Procedure Technique for Testicular Pain

(5) Alternative Procedures Following Ineffective Nerve Block for Testicular Pain

(6) Nonsurgical Management of Testicular Pain

(7) Management of Mechanical Causes of Testicular Pain

(8) Drive For Men’s Health Initiative

(9) Engaging Patients in Their Care

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[Dr. Jose Silva]:
This is Dr. Jose Silva as your host this week. And we have the opportunity to have, Dr. Jamin Brahmbhatt. Dr. Brahmbhatt specializes in male fertility, sexual dysfunction, and chronic testicular pain. He earned his medical degree at Boston University School of Medicine. Then completed residency at the University of Tennessee in Memphis. He completed a fellowship in robotic microsurgery and infertility from the University of Florida. Currently, he's the director of the pure clinic in Orlando with Orlando health medical group. He's active in many provincial organizations, including Florida Urological Society where he was the past president in 2021.Part of the AUA and others. He's also the co-founder of non-profit initiative drive for men health, which raises awareness of men's health. Jamin, welcome to BackTable.

[Dr. Jamin Brahmbhatt]:
Thanks for having me. I'm so excited to talk about ball pain with you today, man. as I'm sure your listeners already listened about that.

[Dr. Jose Silva]:
So that is exactly what we're going to talk about: ball pain. Unfortunately, it's one of those topics that you see often in the office and really you don't know what to do. If there's no tumor, if it's not hydrocele or some obvious pathology, what to do next.

[Dr. Jamin Brahmbhatt]:
No, you're right. It's absolutely frustrating. If you look at your clinic schedule or if you look at even the other podcasts, you've done it BackTable. You got things about cancer and opioid, and you got stents and stones and,very little on testicular pain or very little on chronic pelvic pain. It's just like our clinics. Most of us actually try to avoid this because it's unknown and patients can be a little bit crazy. But hopefully after our conversation today, it's no longer something that you try to avoid. And you try to assist and facilitate as best you can. So the balls don't have to suck.

[Dr. Jose Silva]:
Definitely, because most of the time you feel frustrated with these patients. I mean, like they come to you, they have probably already been from doctor to doctor jumping around and nobody has really done anything. I mean, they do maybe pain medication. Everything's normal now so they go back home. So how do you go about involving testicular pain?

[Dr. Jamin Brahmbhatt]:
So it's interesting you mention pain medication and they go back home. I was just listening to your BackTable podcast on the opiate epidemic and how as urologists, we should be really cognizant of not prescribing too much and thinking of alternative therapies. This is one of those things where they're usually not seeking drugs. They're usually not seeking pain medication. Yes. Out of a hundred patients, you may see maybe one or two that may be kind of like searching for that script. But a majority of them are very legit, but the reason when you're seeing them in your office, and they're so anxious and they're so stressed out and they seem so overwhelming is because you're probably the number second, third, four fourth doctor they've seen. On average patients have seen about seven Health care professionals, before they get something done with them. In our office, we've seen over 8,000 plus men with some degree of testicular pain or groin pain or pelvic pain. So we have a lot of experience. But we can also tell that a lot of these patients, they're not really looking for pain meds and not really looking for surgery. What they're really looking for is just someone to listen. And that can be hard when we have busy clinics, but I think it is definitely something we can do a better job of. Now you mentioned how I got into ball pain.

[Dr. Jose Silva]:
Yeah exactly.

[Dr. Jamin Brahmbhatt]:
So you asked how I got into the whole testicular pain realm. I have to give kudos to my, fellowship director, then he was my partner and my mentor, Dr. Sidra Paricodel. So Dr. P as we call him actually did a lot of the pioneering studies on particular pain. There was some things that we had to offer patients. There were some research, but no urologist was really focusing hours and hours of research. So Dr. P when he kind of finished his fellowships, he kind of really took a deep dive into testicular pain and trying to help these people. I was fortunate to meet him when I was a resident, and then I got to know him and then I joined them for a fellowship for a year. And the rest is history. Like I kind of fell in love with what he was doing and what we were able to do for patients. And then we became partners, and we were together for almost eight years. That's how we became testicular pain experts. That's how I became an expert because he really took a chance on me and took a risk, on the whole thing. So he gave a presentation at the AUA like way long ago, like before I even started my fellowship. So this was almost 10 years ago

[Dr. Jose Silva]:
So that probably is the first time that I saw somebody talking about testicular pain and said what do you mean. You often will see nobody talking about it.

[Dr. Jamin Brahmbhatt]:
And back then, there was so much backlash. Like what, what are you doing? This is crazy. And you go to the AUA this year. Every third talk is about either mental health or physical health or pain, or being able to help these patients. So, the dynamic has changed and I think people in our field have definitely embraced some of these kinds of anxiety, personally anxiety provoking diagnosis.

(1) Difficulty Seeking Care For Testicular Pain

[Dr. Jose Silva]:
Like you said, you mentioned that those patients come to the office frustrated that doctors all say “Hey, everything's normal” or “Don't worry”. I mean, they think they're crazy at some point, because doctors think they’re making it up. So most of the patients that go to your office, are they referred by other urologists, or they're just looking for options? Are these naive patients that they haven't seen on all urologists or the most common patient that you see?

[Dr. Jamin Brahmbhatt]:
I think the referral pattern is definitely equally divided. I would say yes, I do have a stream of patients that I refer to to us specifically because they know that, you know, we deal with these patients, but we live in a very Dr. Google tech savvy, world now. So there are patients that reach out to us, whether it's on my personal social media, which I try to avoid, but, you know, either through our website or sending us a message or reaching out. What's interesting is a lot of the direct connections that are made to us. They usually start off with, can you help me? It's kinda like, oh, you know, you it just takes the guards down when that's how they start off with, Hey, can you help me? I've been through this, and this. So, when we get these messages, obviously, we get them in as best we can. Yes, we're based here in central Florida. But at the same time, with virtual care, we were able to do virtual things, but you know, obviously when it's something that's procedure driven, people have to come down. But I think a lot of what I do is just talking and going over things and I probably don't operate on every patient. I’d say maybe 50% need an operation. But yeah, they come from everywhere. I don't know how they find us sometimes, but they come from everywhere.

[Dr. Jose Silva]:
I mean the hospital system next to you guys and, the word is out that you're over there. So we're sending a lot of these patients over there. I mean, it's unfortunate that most of the time we don't know what to do. And like you said, most of the time it's listening. I mean, we've seen 45, 50 patients in the office and 20 minutes is sometimes it's too much for that evaluation, which is unfortunate.

[Dr. Jamin Brahmbhatt]:
The way I look at it is like when we have someone with prostate cancer we do; the initial screening, the PSA, the exams, the biopsy, we diagnose them. Then we know our limits and then we send them off to a specialist. I think we should think about these patients with chronic pain of some sort the same way. Like we can all do the basics for these patients and I will talk about the algorithm later. But I think what happens is we don't even get to the history. We definitely don't get to the physical and then boom refer out. But I think we can, if we're able to do the basics, then I think, we can start that trust process that we're trying to regain in these patients, much quicker. So it makes your job easier and even makes our job easier. What's really awesome. Here in central Florida, you got two ball pain specialists now. So Dr. Burtcodles his own right down the street from us still in central. He has his own private practice. And then, I'm with the hospital employed system. So the number of people doing this ais growing and there's like about seven fellows that have been under Dr.Burtcodle’s wing. So you know, there's definitely a lot more places that people can go to find help. It's just, you gotta know about it and you gotta sometimes search for it on your own.

(2) Initial Evaluation for Testicular Pain

[Dr. Jose Silva]:
And hopefully after this podcast, people will start like you said, do it as a team and, do at least the initial workup and, give some reassurance to that patient. Hey, you're on the right track and go from there. So for you, what will be the initial evaluation on testicular pain for that patient that goes to your office? I mean, of course the ultrasound, but what else would you be doing in that.

[Dr. Jamin Brahmbhatt]:
So before I get to the whole algorithm, let me just say this, because sometimes I'll forget it is like, I think every physician out there, or urologist or anyone seeing these patients. You’ve got to examine the patient. So I want to really touch on that. I would say that one out of every six patients I see has a hernia and I'm not an expert at diagnosing hernias, but the ever hernia or something else. And that unfortunately you can only find on exam. And knowing how to do that exam. So kind of going back to the basics of residency is very important for these patients.

But to go over our workups. So with all the research that's been done, so for the patients we have a very structured algorithm. So what I tell my patients or when we talk to physicians that want to kind of help out in their office. And when they see these patients is every patient is going to have a different story. But the structure of the algorithm is based on our experience. And we really stick to that, especially the first three tiers when it comes to advanced evaluation and initial management. So yes, all of our patients get a history, get a physical, we look at what medications they're on. In your history what I think is very important is to find three things in their quality of life that we can document. Because what we're going to do is try to figure out, go back to those three things, to remind them “Okay, you are better in this regard” because what sometimes happens to these patients. They're feeling better from A, B and C, and now they're like, oh wait, but when I do this. So we always make sure in the history, you get as much detail, but try to help them focus. So I always ask, what are the three things that make your pain worse? And then I ask them, what are the three things that you would love to do again? And sometimes they have seven things. I make them focus on the three things.

So the history, the physical evaluation for hernias, varicoceles, other abnormalities. But I would say beyond that, all of our patients now, you know, some people may have already had this done, so people may need it. Every patient gets a cat scan. Cause most of these patients do have referred pain. So up the abdomen or in the groin. So we have justification to get the imaging. I would say about 10% of patients, we find either kidney stones or blockages or something weird inside their abdomen. That could be the referred cause of pain. Every patient gets imaging wise, a cat scan, and every patient gets a scrotal ultrasound. If they're seeing me after suffering this for a long time, I usually get one. If they haven't had one within a year, I get one. If they've had one within the past year, I'm not going to repeat it. So that's my basic imaging. Now, when it comes to lab work, I think going to all these conferences that we go to has really evolved what I do for lab work. I actually definitely ask them their sexual history, libido, but also also try to get basic hormones on these guys. Because sometimes their inability to cope with either pain or life stressors could be things like low testosterone. So I try to do that, at the same time, but that's an optional thing. But the basics is really getting that imaging, the exam and the history when it comes to the initial evaluation for these.

(3) Referred Pain in Patients Seeking Urological Evaluation

[Dr. Jose Silva]:
And in these patients how do you approach referred pain? How do you sell to the patient that this might be referred pain? Because they always say well, but I feel it there. Do you talk about that topic, that is “Hey it's not in your mind. It is real. But it might not be what you think it is”.

[Dr. Jamin Brahmbhatt]:
Yeah, so that is a very tough conversation, right. The reason referred pain to them is like “oh my God, they think I'm crazy”. I do think some of the crazy is the healthcare system making them crazy because then they get anxiety and PTSD from their experiences. So I think some of that is self-induced as well. But how do you tell a patient they have referred pain? The way I kind of describe it is like, all the nerves come from the back. But it's very difficult, even if it's a back issue or some strain in there to get someone to operate on that. But then we know there are different branches. We know, based on our research and anatomic dissections that we've done on cadavers, pathologic evaluations, we've done on an actual cord of the testical. We know that patients with chronic pain, definitely have something called Wallerian Degeneration. Now, not all of them do, but a higher percentage, significantly higher percentage. Just so we know, it's really hot in that cord. So telling them my focus is just the nerves that go down to the testicle and the groin area. I'm not gonna be able to get everything. And as long as I know, based on imaging, that there's really nothing anatomic or physical or surgical causing the pain then I know it's some referred pain. So hey, I'm just going to focus on these nerves. And when you kind of set that precedence with them, like, okay, we're just going to focus on these nerves. What's towards the end. I think they're much happier. You know, the first thing I usually say to these patients is “I can give you a hundred percent of our team’s effort. But I can't guarantee anything”. So zero guarantee. So I think having those initial expectations. The second thing I say is I don't get pain medication. If we do a surgery procedure and it's indicated we will write one script and only one script. But beyond that, I do not refill anything. I honestly don't even prescribe Gabapentin or some of the other alternative therapies for nerve or pain. I say I'm purely here to offer you surgical options based on my experience. So you set the right expectations. You do the trust process by listening to them doing the exam and the alternative and getting the imaging. And I think that sets you up for some kind of success. Whether you want to continue from there, that's up to you, or you want to kind of send them elsewhere. That's also up to you.

[Dr. Jose Silva]:
And after you, the ultrasound, the testicle, a lot of the time there's multiple findings and the patient may have a one millimeter cyst and they say “I have a cyst”. It might have been in the other testicle, but they come already with expectation. There's something causing that and it's something physical that it was right on the ultrasound. Do you tell them how the nerves also as a matter of teaching them? What, really, are you looking for in the ultrasound?

[Dr. Jamin Brahmbhatt]:
You're absolutely right. I just saw a patient today who has a four millimeter cyst. I think it's like a testicular and he had another one in epididymis and that's, that's what he thinks is the pain. So you don't want to discount it, but, kind of look at it. Explain to them. Hey, you never want to say hundreds, like extremes, like this definitely doesn't cause this. This just doesn't cause this. Hey, you know, but at the same time, it could, but you know, it can't and you want to kind of be very vague. You want to kind of like legal, political talk. Right. So, because the second you painted the extreme, their mind goes whoa, he thinks I'm crazy. But I think paying the right expectations, like, yeah, this could cause it, but it's probably more a nerve thing. So that's where the next step in the evaluation comes in and this is what I hope all of us urologists at least can do at a basic level. Cause I think you can really set these guys up for success. And if you don't like doing this and you can send them to a pain management doctor do it. But I think as urologists as pelvic surgeons, this is something basically doing that as the spermatic cord block, it's a nerve injection. It’s so easy to do, but I would say only like 10% of my patients have ever had it done or been offered it. And it's sad to see that, they were referred to pain management to do it, and then they ended up getting 10 of them. I think at a basic level, I think the biggest service we can do is as long as there's nothing else, at least offer them a block. A block is so simple to do. It's so safe to do. And within a day or two of them getting the block, you would know, if this is definitely a nerve related thing. And, where we do the block, there's different ways of doing it. But I think if you add a base, you can do something by putting them on medication there. I think we're going to be really able to help that whole diagnosis process.

(4) Nerve Block Procedure Technique for Testicular Pain

[Dr. Jose Silva]:
We’ll go through but how do you do the block?

[Dr. Jamin Brahmbhatt]:
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. Uh, 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. Is 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 targeted. 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. So it's a very quick conversation. but the block, I know there's been a lot of published data. And for these patients with this nerve pain, a block can be almost 90% effective. All we're looking for really is, is there a reduction in pain? We're not looking for complete resolution and me, what I'm looking for is those 1% where sometimes a block can make them worse. So that's the last patient, I want to do something extreme on, so it's diagnostic and therapeutic.

(5) Alternative Procedures Following Ineffective Nerve Block for Testicular Pain

[Dr. Jose Silva]:
And in those patients that say it works. How long does it last?

[Dr. Jamin Brahmbhatt]:
So, depending on what, what, what, we're injecting the Expearl when we add the Expearl, it should be about three to four days. when we're doing the Lidocaine Marcaine maybe a day or two days, but dude, you'd be surprised. You know, sometimes all we do is a simple block and they have no pain forever. So we do sometimes hit the jackpot. I don't know if we're resetting the nerves you know, maybe it's some psychosocial component. 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.

[Dr. Jose Silva]:
And those we will do robotic and microscopic?

[Dr. Jamin Brahmbhatt]:
Absolutely. So a robot is really a substitute for a microscope. Okay. So if you have a microscope, you can do it that way. Yeah. I want to do what the robot does, you can do it that way. And there's actually been studies, published, looking at the cost of both. And they found that the cost actually comes out to be the same at the end of the day, when you look at all the different supplies and assistance and everything needed. So, I hate saying the word robot. Because I do feel like sometimes in our field, like, oh man, they use a robot, it’s just marketing, it's a gimmick, blah, blah, blah. That's what they said about kidneys and prostate. So I’m always honest with my patients. I'm asking my patients to trust me , because they come to hold my hand afraid saying, “you're gonna use a robot, you're going to turn the machine and it's gonna fix me”. I'm like, no, no, no. The robot is just a tool. It doesn't make your outcomes better. It doesn't make your outcomes worse. It's something I use in the operating room to get you the best treatment and outcome possible. But yes, it can be done both ways. You need something that's microsurgical because the tissue in there is very, very fine because you want to be able to cut and divide as much tissue as you can.

[Dr. Jose Silva]:
And for these patients that do improve. Let's say that, you mentioned athletes, he's really concerned with movement. I mean, when does a muscle become part of this equation and the role of physical therapy in these patients?

(6) Nonsurgical Management of Testicular Pain

[Dr. Jamin Brahmbhatt]:
So you bring up a great question. I'm glad you did, because people are going to think I'm just a 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. Yoga, 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. But, yes. 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. Jose Silva]:
So you mentioned medication. I mean, anti-inflammatories for 30 days. What type of anti-inflammatories are you using?

[Dr. Jamin Brahmbhatt]:
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. And if that doesn't work or if I want to add something else, I may venture into Gabapentin or Lyrica. But I'll usually talk to their primary care doctors and kind of take a joint effort on that.

[Dr. Jose Silva]:
And for patients, for example, I mean you're doing a physical exam. You palpate the epididymis and its tender or at least they feel it's tender. I mean, on a physical exam for you, you are essentially normal, but they felt something, those patients had no history of prostatitis, nothing like that. In those patients, do you think antibiotics might work? I mean, or how do you decide which patient gets antibiotics, which one doesn't and which antibiotic do you use?

[Dr. Jamin Brahmbhatt]:
You know, there's what I should say on this podcast, and this is what I do in the office. Right. So, sometimes we're afraid to kind of, you know, say what we're really doing, but to be honest with you, if they do have that like really tender, epididymis, I will put them on antibiotics, but obviously, yes, I'll still do the urinary workup and check for STDs and all these other things. But I usually will. And it's usually for about 30 days. I used to do Cipro, but now there's a lot of resistance to the black box warning. My go-to right now is Bactrim. If they have some kind of allergy to it, I'll look into some other things, but, something I've been starting to experiment with as well as as far as pure drug experimentation. Cause I'm trying to see what works is just going for something like Cefdinir, which we give, like a lot of our implant patients it's like the strongest and I don't want to be part of the resistance program, but I may just try seven year. But what I sometimes do with these patients is like, especially the naive patient. Let's try antibiotics for a week or two, and then you do the steroids and then you do the anti-inflammatories. We’ll kind of write down for them that yes, you can start everything at the same time, but we're going to do a stage approach, kind of like how I manage my overactive bladder patients. Now I give them two different scripts, two weeks here, two weeks here, let's see what works, come see me back in a month. So I've kind of tried to figure out how can I maximize what I want to test out. And that may require some finesse in terms of how we're telling them to do it.

(7) Management of Mechanical Causes of Testicular Pain

[Dr. Jose Silva]:
And that depends more or less on the history, physical exam by the way. So for example, today I saw this patient, only testicular pain when they ejaculate. And I mean, the way they describe it is like the testicle is going up. So you say, well, maybe it's because of the muscle, everything tight when you have ejaculation, do you tackle those patients? What are the, I mean, muscle relaxant works in those patients because I have patients that sometimes it works most of the time. It doesn't.

[Dr. Jamin Brahmbhatt]:
So you mentioned muscle relaxants. Like, I haven't really mentioned that, because I think people can get hooked on those too, like Flexeril and stuff. Like I sometimes have back pain. I take it. So usually, you can try it. But in that case, I would usually like do a block with the steroid and then say, Hey, go ejaculated, have sex, that night or the next day. So I'd rather test it out that way and then put them on something that's gonna, you know, make them high. Like at least that's what happened to me when I took Flexeril for my back. So, but you know, I just kind of figured out a different way to test it, but you know that patient, I would make sure that I haven't had a vasectomy. I also find a way to kind of take a deep dive in any sexual abuse in the past. Now I know we don't have time to talk about that, but like I do do a really, I try somehow to, after we build trust, kind of get into that department because you'd be surprised how many people you know, sexual abuse has led to some of this, that this sensation of pain that they're having. But if they had a vasectomy, it's one pathway, most of them, they have it. What's really interesting for this is I usually will start by trying to put them on Flomax for a month. I know there's some stuff out there that shows that that can help with ejaculatory function and pain. I tried, and sometimes it works, sometimes it doesn't work, but what I've found is these patients often have something called retractile testicles. So they just have a very spasmodic cremasteric muscle. It's really hard to assess where sometimes, you know, you can kind of shake the side of the thigh and, you know, see if it's reflexive. But a lot of these patients, if you kind of look at. But with a close eye, you'll see sometimes the testicle just rides a little bit higher up in the balls. And they're just very, very sensitive to that touch and even like your hand moving through. So then I asked him, “Hey, when you were having this pain, does your testicle kind of ride higher up?” And I would say a large percentage of them say “Yeah, it does”. And so then it's like, okay, well there's something mechanical. These guys do really good with the neurolysis because the neurolysis, since what I'm doing is cutting off the cremasteric, that's where 80% of the nerves are and all the branches that go down into that area. So when I can keep that testicle down, a lot of these patients do really, really well. Because yes, I'm doing the nerves, but I'm also cutting off those reflective muscles at the same time.

[Dr. Jose Silva]:
So definitely good to know. Cause I have seen those patients about really know, don't know how to treat them during the office and just by them putting down their parents its already up in the pelvic area. It's like, it's trying to hide from you. So good to know that there is a treatment. So you're going to see, instead of just saying ball pain, they do this, or at least every four days, I'm going to tell you now.

[Dr. Jamin Brahmbhatt]:
Or if you have questions you can go to our website, myballshurt.com. We actually own that domain name.

[Dr. Jose Silva]:
So yeah, I mean, I want to also talk, I mean, you also do fertility. You do multiple things. I wanna talk about varicoceles. And I don't know, at least in central Florida, we see a lot of Hispanic population. And for some reason, I mean, I would say most of my patients from Latina or South America, they always talk about varicoceles and most of them either have had varicoceles in the past and their brother had the varicocele and they all had the surgeries. But none of them actually say, hey, well, I had problems with infertility, just maybe some pain. And then the pain came back. So they never got cured.

[Dr. Jamin Brahmbhatt]:
I can't believe you just said that. It's been something I'm thinking about in my head. Cause I do see a lot of Hispanic patients, Puerto Rico or, you know, South America or they live here now. And I'm like, they've all had varicocele evaluation and you're absolutely right. I'm like, yeah. it doesn't make any sense to me. Whether they even had varicoceles and a lot of the times they still have the varicocele.

[Dr. Jose Silva]:
And they have the pain. They have both, they have both. So in terms, I mean, what's your approach to varicocele? When do you have the surgery? cause when I was training, I mean, it was fertility ages. When you were in pediatrics, you would measure that testicle, if one didn't grow as much, then you’d do it. Uh, definitely no grade ones. maybe grade two, grade three. So, do you go for there?

[Dr. Jamin Brahmbhatt]:
So, you know, obviously as urologists. You know, we kinda know that varicoceles really don't cause pain. but, you know, when they are the great two and three, I mean, a lot of pressure and weight in that area of the body. So, you know, we feel like the stretching sensation can either irritate nerves or just that pressure, that extra weight can cause some fatigue to those nerves and those areas. And that can lead to discomfort and pain. But I never just fix varicoceles so if it's a varicocele, I never say that's the cause of pain. The evaluations I mentioned earlier are still the same. So we would start off with a cord block. Now, obviously, if they have high grade varicoceles, we're careful not to puncture them. So you may consider doing the block under ultrasound guidance or something. But if I am going to do that evaluation, they do improve, which actually a lot of these patients do with the block. Then, what we're going to do is a dual procedure. So I'm not fixing the varicoceles for infertility, or for testosterone issues or whatnot. I really, when I go in there, I'm going to kind of take care of the potential cause of the problem for the pain. So I'll do the neurolysis and then we'll do the varicocele ectomy at the same time. So I'm trying to go in there and do as much as we can. And those patients actually do, do fairly well.

[Dr. Jose Silva]:
And in terms of the varicocele. I mean, I remember again in training some will do just ligations, some just the removal, the cutting, a big churn of it.

[Dr. Jamin Brahmbhatt]:
So, I do this, you know, the standard sub-inguinal incision, and I actually do go ahead and tie off all the veins, with silk suture and then divide them as best I can. So I know some people use clips, some people still, I don't know why they do it intra-abdominal approach.

[Dr. Jose Silva]:
Well, the reason that you're doing an intr-abdominal is to repair the hydrocele eventually. So you get that extra surgery in the future.

[Dr. Jamin Brahmbhatt]:
I'm surprised how many pages I see that have had, you know, I think IR embolization of varicocele it's, there's very good data, you know, good science. But when a patient comes in with pain, I try to dissuade them from IR embolization because now they've got something permanent inside of them. So yes, if I do this stuff and they still have veins and they're obsessed with them, we'll do it. But usually I'm just, just a heads up. Like I think if you're a urologist out there and you see a patient with varicoceles, whether it's for pain or fertility, I would say definitely. The first thing you mentioned is surgical management of this is a better option. There's definitely a role for IR embolization, but I think you know, I don't want to get in trouble here. But I think a urologist should refer to urologists for this purpose as best we can, as there are resources that may be available in our area.

[Dr. Jose Silva]:
Yeah, I agree with that. But yeah, I think we should take care of each other and definitely I mean, if you're doing these procedures down the street, there's no reason to try to do something else.

[Dr. Jamin Brahmbhatt]:
Really, especially if it's for a patient with pain, like I think getting that advanced evaluation, is very important. Because I only mentioned this because there are patients that are obsessed with the coils that are inside of them. They see them on cat scan and they're reading the cat scan. And then they want me to do like an abdominal expiration. I'm like, oh my gosh. Like, uh. So it does kind of complicate things sometimes. Because they get obsessed with these things.

[Dr. Jose Silva]:
So, yeah, I mean, I think, we covered most points, guess the, the, the, the important part is talking to the patient, setting of expectations, because we talk about those, these small things that they find on ultrasound, they think that that's the cause of the pain. Definitely don't say that like you mentioned, like that's not it, but just try to, put it very big, that most likely something else.

[Dr. Jamin Brahmbhatt]:
If you're in the middle of nowhere. And they're obsessed with like a cyst and it's a reasonable sized cyst. There's no harm in removing it for them. Like I know sometimes we're like, whoa, like we shouldn't be doing that. There's no science behind it. But sometimes these patients just want some help. And if they're obsessed with that point, and there's nothing wrong with going and removing a cyst, you know, I'm not saying do it all the time, obviously the appropriate evaluation. But sometimes it's something anatomical that you can actually feel. You know, it's okay to try, especially, cause it's hard to get these patients elsewhere, but set the expectation. If this doesn't work, then you're going somewhere else. You know, I'll at least do this basic thing for you. One thing I did want to say is when I do see patients with varicoceles plus or minus pain, I do kind of get a semen analysis on them and hormones on them for sure. Even if they're not thinking about fertility, because there's complications with procedures that we do, right? So what if you lose your testicle or something? We haven't lost a testicle in over nine years, but you know, I want to make sure that we know as much information as we can before I put a knife in them.

(8) Drive For Men’s Health Initiative

[Dr. Jose Silva]:
So Jamin I went to talk about, I mean, you, you do multiple stuff. You, you're not just a ball pain guy. You do a lot, a lot of branding, a lot of things outside of your office. I want to talk about the, the, the Drive for Men initiative. I remember a long time ago I saw it in Facebook once. So okay, you talk about it and what it is.

[Dr. Jamin Brahmbhatt]:
The drive for men's health. You know, it was something really cool. So this was Dr.Paracoddle and I, when we were partners, you know, we got very frustrated with how much we could do just in our office. So you could see 30 patients, 40 patients operating eight people a day, we wanted to do something more, broader. It was also our experience with these patients that come in with this pain. Cause there's like incidents of a hundred thousand men a year that have some kind of pain in their pelvis or their testicle. And we also saw that even us as dudes, like we really don't communicate well, don't engage health care as best we should. So. You know, we had this light bulb moment, and that was when he actually got a Tesla. So now every, every time they can hear Harry as a Tesla now, or has one on order and is waiting a year for it. But this is when Teslas were very rare. So what we found was, when he was driving around his car, that all these guys would be interested in the car, and then they would ask him like, Hey, what do you do for a living urology? And then they would open up about a million things. and it's not always erections. They talk about the heart GI like, oh yeah, you're a doctor. So that's when the light bulb went off. What can we do to incorporate the car and get men to start talking about their health. So two crazy guys that we are, we got buy-in with the team and we drove over 24 hours from Florida to New York the first year. We had. we just went like, it was, it was crazy, but they got so much traction that the next year we went even crazier, 6,000 miles, over 10 days. And then we did this for almost seven years straight. We took it global to Dubai and India and other places. And what we found was like, I don't want to take all the credit for it, but I think it made talking about men's health and getting men talking kind of sexy in a way. And it gave people a way to kind of have that conversation. Let's talk about the car. And we actually did these surveys every single year where we kind of found the psyche of men. So men actually know more about their cars and their health. And then we found the top three excuses that men have. So we would tailor our messages every single year. Based on this survey, we surveyed men about things like, you know what, doesn't get you engaged with the healthcare system. So we did a lot and then we drove across and it was a big on the ground campaign, social media campaign. We did all this media and met thousands of men. And what's really cool to see then is like universities had all these men's health initiatives and they use the car as an analogy. And you know, that kind of positive message is perpetuated and propagated and I think it's cool. I think we got to get men talking more and actually me and Sidra went on our own health journeys. We lost 50 pounds. Because the first year we did it, we looked at our pictures like, dude. We don't even fit into a camera like where we were, we were overweight. So then we made ourselves role models because we lost the weight and kind of showed we were one vulnerable. But like we showed our struggles live. And I think, I think men and their partners kind of really resonated with that. So it's a cool initiative. It's kind of on hold right now with COVID and all the changes. But the spirit still lives on, through other people that are kind of continuing the, get men healthier initiative.

[Dr. Jose Silva]:
Do you think he's going to come back or it's a nice memory.

[Dr. Jamin Brahmbhatt]:
Well, um, you never know, man. I don't know. It may not come back and it's true form. But there's definitely going to be an evolution. and the whole process and, you know, just look at the urologist on social media, like you at the AUA, you know, we have like social media forums. Yeah. So like, back then not many of us were engaging people beyond just our offices and now we've got like a whole, like all these troops on the ground on social media. And I'm very proud that urologists professionals remain very professional on social media. At least the people I follow. So, is there a need just because there's a need? I don't think so anymore. I think a lot more of us have engaged the general population. So I think again, I think it is going to come back in some form. I just don't know when, but thank you to all the other urologists out there. Pushing the effort, not just for men's health, but just general health awareness overall.

(9) Engaging Patients in Their Care

[Dr. Jose Silva]:
Oh, yeah. I mean, any other thoughts, any other comments that you want to add? It's been great. And I think, the general urologist audience, have a good feel of, what would be the next step, how to talk to these patients. cause probably that's one of the most important things that we, the, part of talking to them.

[Dr. Jamin Brahmbhatt]:
Yeah, I think talking to them is great. But at the same time and I think you were at the florida urologist society, I gave a talk on you know, the patient experience. I think we can do a much better job of the entire experience and the experience doesn't start when we walk into the office. I mean, walk into the room where a patient has been sitting. I think about the experience and when you see them and they're rushed or they've been waiting an hour or two, like they're already stressed out. So then you're seeing a stressed out patient with pain. I think we can definitely have much more meaningful conversations at the time we have, if we think about the entire experience from the time they make the phone call to the time they come to your office, to the paperwork, to how we're greeting them and how we're making them comfortable and how we're giving them a whole bunch of education beforehand. So we send them a link to our website. Yes, Myballshurt.com. We send them. When they walk in and they're waiting in the room, there's all this information, what we're going to talk about. So I've already kind of started the education process. So when, when I'm in there, I'm just pretty kind of confirming and reaffirming and kind of offering my ear. So I have to type less and they have to talk more. As an overall field, not just for this. I think we should definitely think about that experience. and how can we optimize it? And I think the better experience they have, the less burnt out we're going to get as a profession.

[Dr. Jose Silva]:
And you went, and you mentioned about the experience, have you had problems, for example, for us in the office, we've been having a lot of turnover. In personnel, front office, MAs, how do you, I mean, you’re also hospital employed. How do you deal with that with the hospital having your back in that sense? Because I'll give you the example right now, our lead MA she's going to the float pool because they pay $3 more. And I mean, how the institution that supposedly wants to support you. But the system continues to give you, or offers them better deals outside the office with less responsibility. Can you compete with that?

[Dr. Jamin Brahmbhatt]:
So, man, this is like a whole podcast in itself, but I think if we have the time and I think it's worth the conversation. So, what I'm about to say, not everyone will like, but here's the reality. Number one, your retention level in the office really comes down to your culture at the end of the day. So I'm proud of. We haven't lost anyone. During this whole COVID crisis, people stuck through, I knew there were some who were getting paid less and were getting paid more, but when it came down to budgeting, I'm very hands-on with our admin team. I, you know, we work very well together. I've kind of learned, learned to kind of understand the whole, how the hospital works. It's a big entity. So, I've kind of taken a deep dive into budgeting. And when these meetings happen, when these decisions are made kind of. You know, what's the range that these people make? Okay. What are they doing? When can we ask when we can not ask? So it makes me much smarter when I'm going in for negotiations. Now not everyone may have that privilege or that desire to be that involved, but number one, people will take less of a pay if they have the right structure and support. I think an employed model, sometimes it's just a mistake physicians make is it's doctors versus the rest of the team. And they're managed by admin. And you know, I'm just a doctor. I just do the help, you know, the clinical stuff. No, I mean, I think we all have to be active parts. I try to make everyone, so I think you've got to make everyone feel special and feel like there's no MA versus front desk versus nurse. I think everyone should feel that they're important and valued member number two the way, and this is just our office. But the way we mitigate the loss of people, if that does happen, is we cross train everyone. So obviously yes, there's some rules and regulations to what one person can do and another person can't. But if we cross train everyone in the basic task, it's much easier because then someone can step up and fill in. The other thing is when it comes to equipment and certain day-to-day things that, you know, in one room, you know, the gloves were thrown here and the Tumi syringes are thrown somewhere else. We try to have every single room have a standard, like this is where things go. So if you have the basic standardized, when equipment comes, it goes here in the rooms it's this way. These brochures are always in this rack on row four. And it's, a little, it sounds a little bit anal and we're not perfect at it, but kind of like optimizing, you know, cause I've done a lot of reading on like optimal workflows and how like cars are made or production and how even computer chips and all these things. And what I've learned is all about the automation process and how can you automate it using humans, and you can automate it by providing a proper structure. So I think the second thing to avoid is major disasters in your office. You know, try to cross train people as best you can now, maybe a little bit difficult to do. but like, you know, if you take for example an MA, right? So there's like, we can only do this and the other people can only do this, but if you look at their job description, they can all answer phone calls, you know, like a patient doesn't want clinical stuff all the time. Like you can answer the phone call. You may not be able to get medical advice or vice versa or rooming patients. They may not be able to take the blood pressure, but they can actually still room the patient and talk to the patient, get the basic information that then I can clinically fill in later. So kind of figuring out savvy tactics, you know, that will help us now. The pay part is very difficult. I think it's very interesting. You know, you work at the other hospital. I work at the hospital, you know, we always hear, oh, this person's going to your hospital. And then we hear, oh, this person came from your hospital to our hospital. There's definitely a game right now with, you know, people trying to make an extra buck or two, and it's fine. Like, hey, go ahead and do it. but sometimes you're selling your soul cause you got to commit to two or three years and sometimes you're kind of chasing that sign on bonus. I think it's best. If you are worried about the pay, like, you know, talk to your supervisor or talk to you, you know, your doctor, as a doctor, figure out how much they're getting paid, like you'd be surprised like what the discrepancies could be and then fight for them, when it comes to those, pay scales. And the last thing is I never talk about how much I make, I never talk about productivity. And never talk about our views. Cause then, you know, they just think, oh, you're just doing it for the money right. So then they start getting to that process. So I think, again, it's a multi-tiered conversation, which you can definitely protect yourself by doing some simple things, but then taking a deep dive and other things.

[Dr. Jose Silva]:
Like you mentioned, it's about culture and luckily that the two MAs I have had since I started are still there. But at some point, one of them will leave. She she's young. She's very good. And the system provides for her to continue to grow in that, in the ladder, but then the office pays for it, I guess.

[Dr. Jamin Brahmbhatt]:
Like our supervisor right now was a rockstar. She started off as an MA. So kind of like, you know, what are the opportunities to grow in the office? You know, I told you, I tell my patients, like I can't guarantee anything, but I can give it to you with my effort. So I tell the same thing to all the new hires, like, listen, if you want to leave, I'll write your recommendation. I'll write you your recommendation. I want you to grow. And they're like, oh, I can grow. And, and then they kind of don't look the other way, cause they're like, okay, I can always have the opportunity, but here's a little trick that people don't know. When you have someone coming in. So I actually try to interview as many people as I can that are coming in. Now we've grown so much. We have like 20 team members. Now it's hard to kind of keep track of it. But, when HR calls, I think this is something you've got to tell people that are trying to work for. You make your calls and they throw a number at you. It's a negotiation and people don't know anything. Okay. They're offering me X dollars. That's it? The reality is there's a scale. And so if you don't give them a counter. You know, you're not going to get something bigger. So obviously they're going to try to, don't try to low ball you, but they're going to try to see, you know, if you'll take the bait, it's kind of like when we get our physician contracts, right. You look at the first draft. Okay. I'm a urologist, you know that, right? So, you know, you gotta know that it's a negotiation, so it doesn't matter if you're an MA or a front desk person. Like, I mean, if you're a physician out there and you're trying to get them in, like let them know that you can negotiate with HR, you know? Cause they need you, they need you way more than you need them. When it comes to some of these jobs.

[Dr. Jose Silva]:
Good. So Jasmin, like you say, I mean, this, this can be a full and it will be a full episode. And we'll talk again at some point about branding and all the other things that you're doing, how to elevate yourself and make yourself important in a sense. Ang go more from just not from the office, go inside social media. And like, run yourself.

[Dr. Jamin Brahmbhatt]:
Yeah. But, just for 30 seconds, You can brand yourself and have all these online things, but do a Google search with your name at least once a month and see what's being posted about you or what's there about you? I found pictures of me in high school. I'm like, whoa, like delete, delete, delete. So once a month, you know your branding, but also make sure you're kind of shaving and grooming yourself once a month by checking your online profile. Because it's not always about what you're posting at that minute in time. Always go look back and make and protect yourself. And last thing is, please follow me on LinkedIn. Like I think there's a lot of social media platforms. I think that us as urologists. Yes, Twitter is great, blah, blah, blah. But I think LinkedIn is very, very important, very, very strong. And I think that's where we can all really come together professionally. So I think that is, my go-to platform. Right now. So

[Dr. Jose Silva]:
LinkedIn. Perfect. Yeah. So, so definitely. Dr. Brahmbhatt and, definitely check, go back and do what the Jamin’s doing,google yourself and especially more after being on a weekend in New Orleans. You know, I don't know what happened.

[Dr. Jamin Brahmbhatt]:
If you find your name and website called YouPorn, then you probably call a lawyer.

[Dr. Jose Silva]:
Okay. So I mean, things will be on BackTable. We'll talk again at some point, and talk about more stuff.

[Dr. Jamin Brahmbhatt]:
Thank you guys. And hey, strong work with the back table, team here, you guys are doing an amazing job. I love listening to your podcasts and they get better and better every listen. I do so kudos to you guys for being advocates for us in urology and our patients with the messages that you're resonating through social media and the podcast. So thank you guys.

Podcast Contributors

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

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.