@DrAshBowen. ll Pain: Solving mysteries of the male scrotum

Transcription

1 @DrAshBowen ll Pain: Solving mysteries of the male scrotum

2 On the Docket Good Hydrocele Epididymal cysts Varicocele Bad Testis Cancer/Tumor Epididymitis/Orchitis STI Torsion UGLY Chronic Orchalgia Post Vas Syndrome Spousal Revenge Syndrome

3 Objectives Describe conditions that may produce scrotal pain Determine which scrotal conditions require emergent surgery Form an accurate differential diagnosis for scrotal pain Establish a pathway for the treatment of chronic orchalgia

4 Disclosures I DO NOT want to be the ball pain king of Oklahoma I DO NOT have any financial conflicts of interest.

5 Hydrocele Cause Differential To US, or not to US Treatment Surgery Drain/sclerose Cause Differential To US, or not to US Treatment Surgery Drain/sclerose

6 Epididymal Head Cyst (Spermatocele) Exam Reassurance Diff Dx Surgery only if bother Reassurance 17% risk of obstruction with removal

7 Varicocele 15% of all males 10% with pain, Si/Sx Pain Infertility Hypogonadism Surgery Outcomes 2.8x more likely to get pregnant 60-90% pain relief Improvement in Testosterone levels

8 The Red Herrings Nephrolithiasis Appendicitis Back pain, Lumbar disc herniation Neuropathy

9 Epididymitis/Orchitis DO NOT GIVE CIPRO DO give NSAIDs Rule out torsion CDC Guidelines <35 yo Ceftriaxone 250mg IM &/or Doxy 100mg bid x10d 35 yo Levofloxacin or Oflaxacin x 10 days (add ceftriaxone in MSM 4-6 weeks may be needed for chronic epidiymitis

10 Vaccines Cause Adults Mumps Orchitis Sudden onset orchalgia, swelling Abdominal pain, nausea & vomiting Preceded by parotitis Supportive treatment

11 Testicular Torsion Generalized testicular pain & absence of cremasteric reflex Other: Nausea 10-60%, scrotal swelling late Associated with rest or activity Decreased Reliability of CDUS Sensitivity 63-90%

12 Torsion Continued Outcomes Risk of Orchiectomy 5% at 0-6 hrs 80% at 24 hrs 75% of saved testes will atrophy if >24hrs

13 Fournier s Gangrene When to walk Fever, chills, malaise Erythema, swelling, pain, warmth When to run Fetid odor Necrosis Pain out of proportion to exam Air

14 Chronic Orchalgia ~5% of Urology patients 18% may never get satisfactory explanation 40% may be idiopathic History and Physical are key What antibiotics? Rectal exam, pelvic floor

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17 UPOINT

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19 First Line Treatment NSAIDs Meloxicam mg daily Ibuprofen 600mg TID Antibiotics 4-6 weeks Appropriate medication <35 doxy, >35 levaquin

20 Pelvic Floor Physical Therapy Can be curative in up to 80% Neuromuscular reeducation (EMG, Biofeedback) Manual therapy (Soft tissue mobilization, Myofascial release, Connective tissue mobilization)

21 2 nd Line Treatment Tricyclic Antidepressants 27% Major depression, 56% somatization disorder Amytriptyline 10-25mg daily Nortriptyline mg daily Lyrica/Gabapentin Gabapentin 300mg TID Pregabalin 50mg TID

22 Cord Block and Trigger Point

23 Surgical Therapies Microscopic Cord Denervation At 6 mo, 86% improved, 52% pain free Epididymectomy Complete response 10%, Partial response 88-90% Orchiectomy Decreased pain in 40-75% Strohm et al. J Urol Calixte et al. Curr Urol Rep

24 Epididymectomy Hinman et al. Atlas of Urologic Surgery, 2 nd Ed.

25 Microscopic Cord Denervation

26 When all else fails Spinal cord stimulation In-office test 86% improved VAS from 7.6 to 2.4 Small series Cord cryoablation 70% improved, 5% resolved Scrotox 62% improved, 7.5% resolved

27 #SQ788 Canadian Meta-analysis, 169 pts with neuropathic pain, 6 trials Deshpande et al. Can Fam Physician 2015 All trials showed statistically significant decrease in pain, longest trial 8 weeks Only 3 of 6 showed clinically significant improvement (2pts on 10 pt VAS, 30% improvement) Safe, well tolerated

28 Post Vas Pain 15% early after vasectomy <1% beyond 6 months Start with NSAIDs, scrotal support, ice/heat Surgical Efficacy Excision of granuloma Epididymectomy ~50% Vas reversal ~69% Nerve ligation 75-85% Orchiectomy 55% scrotal, 73% inguinal

29 Spousal Revenge Syndrome Occurs in men who have some type of sexual encounter outside of committed relationship Symptoms of STD Work up negative 100% pelvic floor spasm Treat with PFPT May also occur in female spouse after husband admits infidelity

30 Pediatric Scrotology Rule out torsion Epididymitis If pyuria antibiotics, if UA normal supportive management If post-pubertal, low threshold to treat for GC/Chlamydia Perinatal torsion Torsion of the Appendix Testis

31 Pediatric Scrotology Cont Henoch-Schonlein ሷ purpura Scrotal findings in 2-38% Edema, erythema, hematoma, torsion, epididymitis Choose Wisely Don t routinely order US on boys with cryptorchidism

32 Conclusions You can do a lot with out an ultrasound, use your fingersound You can make a big difference in men with chronic orchalgia before they see a urologist Don t fear the scrotum Get an Ultrasound on kids with acute scrotal pain

33 THANK YOU! QUESTIONS Contact info (405)