Smt by ne Ota toon CHRONIC ORCHIALGIA IN THE PAIN PRONE PATIENT: THE CLINICAL PERSPECTIVE RAYMOND A. COSTABILE,* MARK HAHN axp DAVID G. McLEOD ‘Prom the Uta Serial Pan Managemen Clin, Waar Rd Army Ail Center, Wshngtn D.C and Ure Serses Thiers te Heath Sn, Bete, Main CChronie pain syndromes are well knowa tothe medical community. The incidence of chronic pain syndromes and cost of evaluating these patients fairly common manifestation a a chronic pei eapilyinereasing. Chronic testicular pain is 8 Syndrome. Retrospectively, we reviewed the records of 48 patients with chronic testicular or serotal pain (greater than 6 months) evalutted a. out institution during the last 7 years. ‘These patents hed multiple diagnostic and interventional procedures with few positive findings. There was litle improvement in these patients after multiple Surgical procedures, Based onthe paucity of objective clinical findings a carefully directed diagnostic ‘valuation for orchialgia is outhned, The treatment of these patients is best managed by ‘multdisciplinary approach involving the urologist and e pain cline entironment. We believe that extensive diagnostic testing is not indicated in the absence of clinical findings and mey serve 10 ‘worsen the condition or lead to iatrogenic injury. Songial intervention shouldbe limited to casey ‘when a clear indication ie present ‘The incidence of chrome pen syndromes hes intend in smademn societies during the Ist few are. The meal os ‘any ie well acquainted wath the lage numberof pati with low bak and chrome pale pain Many of these India Ue wer from pvsican te physician, nrening lle Aiagostie and interventional pred in to ‘ascertain the etalon of the pin and ace these precedare serve oly to bwser the ptt ad phys {Ganvandoften exacerbate the complaints fe hasbeen oid, {ht 'the year owt of Tow back pain alone inthe state of Caltenia inthe 1370s exceeded 200 malian dllar The ‘slimate of health cae costs oly and dows a begin umate the les of work tne on proto. With chronic in sVodrenee approving near epidemic Proportion an fo must be ide to stamiine metal evasion and ‘apy ron these patients funetanal members of sci ‘Althoorh extensive irate ha een devoted to anasting {the charactertice and ctiloy of chon ow back pin tere Felden the uroloteal iterative concering the soy ant {teatent of orclalga® As the Ingest medial center the United States" Army. out inition har eased lar suber of redoing oun cv day ps no ave ten sclered for dinpositon iter excenive’valeton of throne tesurlar pan, Thin, we wore aie to retew tht Imei records, work tate ingnstic evaluation, previous trentownt and fesultant condition Aer extensive review the cel ndings we were able to outine n efficient dae ati eels for chronic testicular Pai Based ne Tidings when a thor history nd pices exxminaton cs to indicate an obvious etiology few invaive tata are mood [ARer @ review of the trestenteptone valle fo thee Patients o elev that surgical imervention rarely i ind Sted. A tuliscplinay, lng term tentment progr Solving health care provides familar with chron pa a eement is mandotos. "The sail of yin we out Lmaon for chrome testicala and arta pln wre refereed othe urlogy sere ‘coped option Aa 9,190) cae aac: Unpreet Uilgy, Uriery of Vin ‘ah Sener Cnr Ebel os 3 deg mn a et ri ide gated bree eta Sie earn ae ee gra SSL Gr fess iene ore re Seog nots Seem a psa Rennie pie acter tS htc eas Soe irises base seer rah reeanaienaea as rei Ss ican ie eae ton tl i Sone econo Characteristics An nals of patents sen au nition shows tha the patent with chronic erchngi o mst een ‘soung average age lear) white man ith an averaged tomo sera psi afSyear ele) Apatite had italy bee seen acter snsttatons and mont fa had ur ane ‘aluation befor pecan. "The muon of patients mere "Tamu 1 Conparion of pit daar in pant ith ‘hind ak in72 "Tam 2 Roto anti prendre performa on pasit ith "Tole ah ee it scsive ity military in elthr enlisted or noncommissioned Siler poetzone Tee tltary secpation of these patents formes with blue collar postion inthe cian sector. ‘White was dificult to evsoate completely the evel of eh liom, moat of ur patios ed completed igh choo! ard ‘nly 35 had ny colo edveation, ‘Digna contin teal of 21 dngnotic procedures ‘nas performed onthe 1 patient neuded in our stay. This umber presents an aera of 8 agnostic precedes per Daten. OF oar patents hod sigicant vouling spe Fabwura frequents, gene nd so forth) Sn adon to the fcrotal iscomfort and they accounted for the maorty of ena sbooral findings an dlagnotc states. Table 2s ‘Dna of the sult of poses encoding the ¢ patente ‘rin voiding detetin. A sinieant ining Was considered {o'be am abaormaliey found om std that mould rere Ineeteon even the abeene of pan. An ncdetal ling trov un anatomical or songertalabnopmolty that normally ‘Rel not require sural intervention hut woul be observed Tee exc patients with voiding defmcton gay 2 0 208 ‘tis les thon 1) showed sigfiant abnormalities, ‘Suro proceduren A total of 1 alleen sured proce dyes nat prfoted on oor 48 pain, netting epee {Say nd, vasele gation sn 1, scetal/inguinel explora ‘Gon in, oeceomy 10, vesectomy in 9, brn real ‘TPtansursheal yateton of he prostate o blader eck 3 Soother procedures in 13 Allprocedares were dove 6m Attempt fo define and treat the fom of scrotal ein: Hach Fon underwent an average of 16 operations Loc anes ‘lst blocks and preatancou ablation wore nt inte in ‘he eoup and each patient meqied an aesthetic episode for ‘he procedure: Some patents underwent es tanya oF © ‘opertions ina stenpt to et the complaint The pathoog- (Er ret of tae removed wae benign andthe priry ingroi wes normal tesoe with m0 pathological diagnose (G08) Ten patients underwent orciectoms fr pain and ony epetinens (0%) bad mini focal tubule trophy» dag ows no naive of ehronc pain etiolony- A othe pet fens (a!) had normal testcular see. No compliations ‘ere ited rom hese eel procedure. Water # years of seauntion 31 patients wore avlable for followup A total of 2 pation continvd to have testicular {Snorscoal pain tha was sale we unchanged. Only 2 Balen hed improvement in pan ater mule operations nino patent had esnition ofthe symptoms ileen patients ‘tee granted ideal iclge fom the matary based onthe ‘Ghose origin, We curren are cvalunting the sce of ‘ain misagementecbnigues ith these patents Pin ie an extremely abstract concept tha is difeul to dine Mezskey and Spear ured an indvidval description of paisa an unpleasant experience which we imariy uocate ‘ich tour ditagy or deveribe in temo roe damage, oF otk" defstion wonke well inte ntting of sete pan ut loss it vaiity inthe patient with ehronic pain, To ‘neatnd the prone of crane pin Isto eit sway fom {he presumed ste of noceepion toe ore entra or peyho= leptldeseripion. Chrome pani the iva peo ohare Inn vem ti aca nul ne not sap of some [ther malady. Bluner and Hellrenn best descibed the enti Ut conic pain by stating thatthe caput to experienc pain Imny origaly develop from peripherally induced experience {at ialy becomes a seal or pscolopenl phenomenon that no longer requires peripheral stimulation co be provided” ‘This appent fe theese he patient wth rune ohh fin, The majry of our patients appeared to heve had a Feasonae precntating event tht sta scrotal operation oF Inveton) with teating eae pain sate Tote inthe ‘from, In the situations the patent and physton art ‘lsperatel loking fora cust of te pan, ard serie of tvnsive dagmoaie ests and mitting operations ensue ut tthe aly urea, What ie eee in hi setting hit away from trerting # nonexistent scrotal pethoogieal ‘Stout to effing change nthe perception of ad coping ‘echanine fo pa Shea Pe rt ete hai ona potent and those wich chreni low back ala ae seking Ute 1) Peshape the most ening characteristic of the Chronic orca patient is he average duration of pin (7 Sear) Pain that oe present for at lest 6 tothe and i sppropete ote findings on clinical exemination way never 2 harbinger of 9 sgn pucelogialorin, Thi i Eonsisten wth thceaneepe tht paints wideclonie ow back fun without definable reprodetble radeulpaths eidom ave {irminent dak or pint cord patoloial condition, Patars ‘hal should lee the physisam to identity the pain prone Indvidul wich rehire multiple pian conta with aay nonprodarive diagnose anor interentional proce ‘ves, excesvepresceupation ith pa, altered ebaviorpat- ferns or eoping sl ple medieatlons and stra eat- Suns and selile adios fearctca end onan. ies). “Dinos ealution, The lack of significant findings on extensive diagno evaustion of the chronic otha pe {lene sveget that «streamlining of hi proces fs needed ‘This creamlining ie ot onl impostant to decrenee moda {ss but It noceany to dereve the sk of Irene ‘Srapestions brghton by avaive testing ‘Ncompete and thocough story a pial examination sathetest mechunis to ently patents ith eo orchial- fds. The lnc of civ physeal findings other than pain foul set the zoos to the posit of patient with {he chrome pain soriome, The physi sboud nat beim [ells y the lek of Findings to imstute or varie proces ‘ite ina eto to net noneistent patiogialcontiton, Only 2 patents in cur say hod a signet, coretable putologitl onion (ladder neck dstunction). a pants Ei significant viding symptoms on history, which were cor ‘horse by sbnonmal uraowet ‘An aalssn of dings proces performed showed that onl sot oasurd hod ry signeat frequen of abaae tal ndings he majority of thas aoreal results wer i the indent gs group and consisted of hydoceles and ‘Suall sical varogles While Uae condone mah Fo Feeont posse causes of ea pi, the lack of improvement {her eomcton of ese inert indings should make the {root wary of eogial opasr sce t relive te patent of ‘We ca sfels Hint he diagnostic evaluation ofthe chron corlge patient fo that we inte frre. Alshough sels ‘std he ondersing fee of psn and paint chat ff missing an eect neoplanm In patents with pain erste {han © mopihe i ration, and normal plyscl examination Sin sro liso ths sk ie pacticaly nonexistent. ANDaou alee ipa ‘ene sboormal urinalysis or culture shouldbe investigated in an ate manner. Bile. he nts andl bckaround of cone ann hie jrovp are myriad and uten contsing, However, sanities Ftveoen und nthe pyehoseie maka the patent wth le back pain" Theres higher incidents of eel dees ibm andres spectrum anders ist dete lates ot patents wth eon pin than in Contr subject The Snethesi pain management iterate upset the ind ‘ial prone to have pie may manifest pain ea depen uae The Minnesota Matsphase Personality Ieventory ‘iw a higher depresive scare greater than 70%) for these patients over control "his findings conmstene with he Evmptoms of enhedoni, icons and eer. although to Patients wth decom pain ome show idence of et nia depeson a complex relationship exists Between pa {ou deoresion. Thee pans, when glestoned. wil sen deny any depressive svptons dn lane eversthing on pa, Unrate hin de end too bel gerpeetng eeu bain to depreanion to sulin to abil. Pasholoal festingwll often show estrone cna dares boomy Sep testing coofinns the igh incidence 9 sor he Bun prone idiidual” Besties shoral ves Indeting ‘keine equivalents in the Minesots Multiphase Person Is Inventory and ober peshologeal est, hen nds Show a higher incdence of cinicallyabormal dexamethasone ‘presi testa’ These patos wl eapond to andres eter. ‘leary ber factors besides depression must be preset in the invidal prone to have pan, Som physics mages {bat this epee equivalent sat ony present fn apo ney $08 fal mts ih chek pa Se ane Strgeted a diturbance in he eatine ban wc ee Unter these chroni pae sete: Poor sem Upake he ‘Spinal pain tact hasbeen sagged ts posible alt Aatideprosants ae bleed to ert stration nti ap by blockading serotonin uptake allowing it torent the sony aes sal ymaptic eet. Adina, 9 postive corelation has ben {ound between high endorphin levels the central merous ‘ystem in patent wi evone pan and thane with ena ‘kpression "Pinal, the urolge must b awe ofthe relly secondary pun in these chron ocbaigi patients: Ces tainly apercentaea these patents wilfully maniputte thee ‘Shmptons inane sre Inigaton or final comer Shion. "This eoup represents monty ef conte fl pe Treatment Unfortunatly the treatment of te patent with tome pan sitet fstating and length forthe Ps ‘in andpatien- Ls portato tte patients ear, Sdtoolminato ad andnefortuldingoser Picante find that thee patent ge adele septa of symptom And are often couvined that sural manipulation wil she {he problem "Tis couldnt be further fom the eth need, lengthy and involved diagvostc pcedures may agate rather than Unprove the stunt’ ‘Thete ole ee com ‘euene of surgical stervention followed by be itera of improvement with subsequent recurenc of pus, OF cay pe tiems BO continue to complain of seca paste och ‘ne he diagnos of chon oni i eognized tnd no lear etiology ean ne dacrned, other agate poveduts are upriuo nd potential har a sure nerves ‘hood be avoided. While tei nfl tment tn phe ‘in-patient interaction, x important to oe ak Plea tnd dos osur i tho absence of mechani! lors en there inno hidden, undiscovered aliment: Nevertheless, the pa Se furuine and not de toa ocd ematve protest to 8 Malfunction nud the nervous year Isnt produ ‘te that he pres pchogenic “Thebes restment forthe patent with chronic pain involves «mnultiieiphinary approach posible sing’ ain unage ‘mont cline. Mulople teattienttodalites ten are needed Siu Tone westent atereal i antpated. Many oneal ‘erapesie techies inlve enanry tnaision, which ‘nay be accomplished through bofcdhack teasing br ith fountratita therapy. The tanscsnenae elec ere Fimulator has Been Bp many of our patents with ‘hronesroal pin The mechan of atin ofthis vie ‘recom unclear nd certain te Paces fet re. be onsite A til af naeutanes etic neve stimle tion for to 9 months is safe and potently of sme heeft Physicians and patos chuld be wing ta acept tanta: ‘neous electrical nerve simslation ta simple empirical et ‘ont with no sid fete Insts on patents wil oe back rnin SY tated thatthe pain woe eproned by sing this tevce." We bas nat eccllected aust dataon the nasees bf transcutaneous eectial nerve simon in patines with fxchilgs ut we belive that our success re somewhat tomer. The ony eonrindcation to rents lect neve simulation would be the present of» pacemater. ‘While the clea relaonship tetween depression and ‘hone pain unclear, many pests we chronic ala wl improe'on al flow doe sotdepesantRerponse ates of to 70% have been repre for patients with ow back seis impr arth au dae edn ed fitgste opaient response. This approach helps to eevee the tide eect of sedation and dsrentation, factors thar cause ‘any ptients stop medication before aching any tere put efect Doxpin ad amitttinn app to har advan tages ovr other ech atidprents forthe patient th chron pin. They eahance serotonin opts bloade ae tell as etblshed amsnytic properties, re eel with {Ihe postntpopnton We ue ster Sogn th 3 ‘me adored abies sds herapeie soe, ‘These drags ae se wit ow carne and hw ane Tinrsc etic Tits ad rks ae sila pani, frag with which mest urls are oman,Anesthesia pin management can be eel forthe patent wirshronsr oraz ty poviing dapnestc and therapeutic Terve bloke "Tes can be administered Toes or tm the {layitton of peripheral or central nerves to deteas pln. foingtnal,lckypoparrc or genttemoral nerve damage can trea sscondary ener of chrome ert o inguinal pun snd ferve Hocks py prov spl a fbese patente" Once the “gnosis ofthe ehronte pain sindrome Bas been made these Invasive procedure shouldbe avoided "Oreste uporeant that I phyaan identify and eontol ‘he mnnaiement of We patient with chronieweeal pln CCoeting infomation on’ peoe medial eaten to ince posible gation or corpetsaton and confronting be patient FiGetoace ae beneficial to rturring these inidoas ‘nctnel mensbers of wees, eis imporant fr to physician font tre that he on eaten na be ‘liminte the pain hu tol the patient to earn co ie wi ‘eter coping inecniame for pis 1, Boni, Js Advances in Neon: ternational Syposiam on Pails Pavey fo pp, 2: ge the cone yl ine Sit CN Ame ges BE Wel, MJ, Weil W, Foret Dan Me, "WR Alans ane manages of ow ester ut Ut te i, CCOSTABILE, HAH’ AND MCLEOD 4. Mentey, and Su, P:Pa: Peal nd Pcie “Spt Ling dl Cam “ "fps ae he pin-prone Corder. Der, Ment Ds Mle and Belin, Cs Ch a nt stun Me 2 oS se a "To thiamin Pog. Md, 8:33 Sand ' Scher ©, Donon. Ta Ble, LM: Choe anand ‘hrs el olay sary eres Are Pa SES te i, lol Chapman CR a Hoe: Pap design “dc ees in «yin case pps. Pa 91 10 Wittig R.A, Zor, F., Blumer, D., Heirons, M. and Roth, id Sn a cir com ‘cin, F and Dai J. M: Diagnose ond Drag Trentment of vehi ate aan ih. "fats the mangemens of hone bn pat& Med 3 81 16. Poth Tedobaeon, Rand MiCrahn, W: Tanuntenele- "ea asta nthe cot eho an rch Bg Mb, 6520186 14, Nowy, Mz Nena management of pin cy fo thal he nse Orth Cn Amer 18051088