In this episode of BackTable Urology, Dr. Jose Silva and Dr. Jamin Brahmbhatt discuss the evaluation, causes, and treatment of chronic testicular pain.

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SHOW NOTES

First, Dr. Brahmbhatt shares his basic algorithm for evaluating chronic testicular pain. He will take a history, perform a thorough physical examination, and obtain new CAT scans and scrotal ultrasounds. He emphasizes the importance of physician examinations in order to find hernias and encourages urologists to ask their patients to name 3 quality of life activities that are affected by their testicular pain. Later, he will use these activities to document patient progress. Dr. Brahmbhatt also notes the possibility that the testicular pain is also a result of referred pain. He makes sure to explain the mechanics of the testicular nerves within the spermatic cord to the patient. He usually does not prescribe or refill pain medications unless they are required for postoperative pain.

Dr. Brahmbhatt offers various procedures to alleviate testicular pain. First, he will perform a spermatic cord anesthesia block (SCAB) if no surgery is indicated. This procedure involves sedating the patient and then injecting a mixture of anesthesia and steroids into the highest point of the spermatic cord. He usually injects 30 cc of the solution, saving 5 cc to inject in the most painful region. He follows up with his SCAB patients in 5-7 days and observes for pain reduction. He notes that this non-surgical procedure is very effective in many patients. Worsening pain after SCAB is a contraindication to surgery. The second procedure that Dr. Brahmbhatt offers is testicular neurolysis or microscopic testicular denervation, a procedure in which he cuts and divides tissue microscopically within the spermatic cord. This is a procedure that can be performed robotically and is very effective for resolving pain in patients with retractile testicles.

Although he offers procedural-based treatments to testicular pain, he always tries to maximize medical treatment for at least 30 to 90 days. Medical options include: 7.5% Meloxicam, a short course of antibiotics (Bactrim), Flomax (for pain during ejaculation), or gabapentin. He will attempt SCAB first before prescribing a muscle relaxant, as muscle relaxant can be addictive. He also recommends specialized physical therapy for groin and testicular pain.

Additionally, the doctors discuss the role of varicoceles in testicular pain. Although both doctors agree that varicoceles are not supposed to cause pain, grade 2 and 3 varicoceles can cause a stretching sensation that irritates the nerves. Dr. Brahmbhatt will continue with his standard evaluation algorithm, even in patients with a known varicocele. He notes that SCAB is very effective in patients with varicoceles. If he has to proceed to surgery to manage testicular pain, he usually includes an additional varicocelectomy as well.

Finally, Dr. Brahmbhatt discusses his non-profit organization, Drive for Men’s Health, which aims to increase male engagement with health care by organizing road trips around the US and the rest of the globe.

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