Chronic scrotal pain in young adults

Chronic scrotal pain (CSP) is a common and frustrating complaint that interferes with daily function of young men. It can lead to long evaluation process and its treatment is often ineffective [1–3].

CSP is historically defined as an intermittent or constant testicular pain, unilateral or bilateral, lasting for over 3 months that interferes significantly with the patients daily activities [4]. This CSP’s definition was stamped by Davis et al. in 1990, after conducting a retrospective study on 45 patients who approached the clinic with testicular pain lasted at least 3 months [4]. This definition was made according to common description of chronic pain as pain lasting usually 3–6 months [5]. However, chronic duration of pain is defined differently in different organs [6]. The prevalence of CSP and its spectrum of etiologies were never reported in the literature. Hence, this arbitrary definition might be inaccurate given the diagnoses’ medical course which causing CSP.

The management of CSP depends on the specific diagnosis or presumed etiology. Therefore, a thorough medical history, physical examination, laboratory tests (blood and urine investigations), imaging studies and specific tests like tumor markers and sexual transmitted disease screening, when indicated are crucial.

The literature is poor in epidemiological data on CSP, its etiologies, prevalence and outcome. Data from questionnaires among urologists in Switzerland revealed a crude incidence of about 350–450 cases of CSP per 100,000 men between 25 and 85 years [7]. Recent data from orchialgia clinic located at Mount Sinai Hospital in Toronto, Canada of 131 men presenting with CSP found that in 43.5% the cause was unknown; Vasectomy was found as the cause of the pain in 20.6%, trauma in 12.2% and infection in 11.5% [8].

The aim of this study is to provide a comprehensive epidemiologic description of CSP using a large database and to challenge the current definition of CSP.

CSP is common and frustrating complaint of young adults. In this research, a large database was surveyed and the authors had full access to the long term outcome of the cases, so the risk of missing important diagnoses is low. To the best of our knowledge, this is the first large scale survey of CSP in young men in a primary care setting. It was found that CSP affects 0.8% of the young men. The mean primary physician’s number of visits was 5.3 with one patient visiting the clinic 37 times. Referrals to specialist in Urology were also common and the mean number of referrals was 1.4 per patient (range 1–11).

The etiologies of CSP in young men are reported in this study (Table 2). Varicocele was found in 54.6% of the patients and was more common among patients with longer duration of symptoms (up to 60.6% in group C). The prevalence of varicocele in normal young men estimated at 15–20% [9] and the prevalence of pain in individuals with varicocele is estimated between approximately 2 and 10% [10], which mean estimated prevalence of painful varicocele of 0.3–2% in normal young men population. We found that painful varicocele was found in 0.4% of normal young men population which is close to the expected rate.

According to Granitsiotis et al. nearly 25% of patients with chronic orchialgia have no obvious cause for the pain [1]. In our study, no specific etiology could be established in 1062 patients (34.4%). The percentage of patients with idiopathic scrotal pain dropped with longer symptom duration. This may suggests that in patients with idiopathic scrotal pain who complain for longer periods of time, further evaluations were done and in most cases, varicocele was found and diagnosed as the presumed cause of the symptoms.

The prevalence of the other diagnoses was quite similar between the different time groups from the shortest duration of pain (15–29 days—group A) to longest (more than 60 days—group C). This challenges the historic definition of CSP as pain lasting more than 90 days that is based on a study of 45 patients [4]. Therefore, we suggest defining CSP as an intermittent or constant testicular pain lasting for more 14 days that interferes significantly with the patient’s daily activities.

Diagnosis of scrotal pain due to scrotal skin lesions, torsion–detorsion syndrome, scrotal trauma, scrotal tumor or nephrolithiasis were assigned in about 1% of patients or less, probably because these etiologies are of acute manifestation or because of the painless nature of these pathologies. A total of 252 (8.2%) patients underwent surgical interventions including: hernia surgery in 46 patients (1.5%) and varicocele and/or hydrocele repair in 206 patients (6.7%). The rates of varicocele and/or hydrocele surgery were higher in group C, probably because of failure of conservative treatments.

The management of CSP depends on the cause or presumed etiology of the testicular pain. The key to successful assessment remains the history and physical examination and early use of ultrasound of testes and inguinal region is the most reliable imaging modality in the management of chronic testicular pain. Lau et al. observed that in patients with testicular pain longer than 14 days, sonography detected lesions in 28% of patients with no clinical findings on examination including varicocele, hydrocele, epididymal thickening and epididymal cyst [11]. Thus, we suggest early referral to ultrasonography of the testes and inguinal region for all patients with CSP.

Testicular torsion (TT) is a relatively rare urological emergency in which the diagnosis must be made accurately and rapidly to prevent loss of testicular function. TT is a medical situation of an acute presentation. However, TT may occur in patients with CSP. In current study, 25.9% of the patients visit at least once in the ED, in most cases because of physicians’ suspicious of TT. Yet TT and torsion of the appendix testes were not found in any of the patients and only 1.0% of the patients were hospitalized emergently for any reason.

We report on the prevalence, etiologies and outcome of CSP in young men in a primary care clinic are reported. CSP affects almost 1% of the young males and can lead to repeated visits to the primary care clinic. Varicocele is found in half of the patients but significant pathology (tumor or torsion) are rare. Early use of ultrasonography is advised. It can rule out significant pathology, reassure the patient that the condition is benign and prevent revisits to the clinic. Considering the similar etiologies with minor variations of CSP over a wide spectrum of time (from pain longer than 2 weeks to pain longer than 60 days) we suggest defining CSP as intermittent or constant testicular pain lasting longer than 14 days that interferes significantly with the patient’s daily activities.

First, our database is obtained from medical registries of the Israeli army and it may be difficult to generalize the finding of this study to the general population. This issue may have affected our results; however, military service in Israel is a compulsory and includes not only combat healthy soldiers but also non-active ones which their life style is similar to a civilian life. Another concern is the fact that the study was done retrospectively with no control group, further prospective studies in civilian population using this study findings are needed. The absence of validated questioners regarding quality of life makes it impossible to evaluate the real impact of CSP on quality of life.