Microdenervation of the Spermatic Cord for the Treatment of Chronic Orchialgia Refractory to Conservative Management Kurt H. Strom, MD, and Laurence A. Levine, MD

Corresponding author Laurence A. Levine, MD Rush University Medical Center, 1725 West Harrison Avenue, Suite 352, Chicago, IL 60612, USA. E-mail: [email protected] Current Sexual Health Reports 2008, 5:59 – 61 Current Medicine Group LLC ISSN 1548-3584 Copyright © 2008 by Current Medicine Group LLC

Chronic orchialgia can severely affect a man’s quality of life. It is a chronic pain condition associated with the upregulation of peripheral and central nervous system pain pathways. Conservative measures such as NSAIDs, narcotics, antibiotics, antidepressants, anticonvulsants, nerve blocks, and alternative medical treatments often fail. In many cases, patients are willing to consider surgical treatment for relief. Unfortunately, there are few studies that evaluate the efficacy of the various surgical treatments, which include epididymectomy, orchiectomy, and vasovasostomy. In our recent series, microsurgical denervation of the spermatic cord provided complete relief in 71% of patients and partial relief in 21%. Relief likely occurs by blocking noxious stimuli from the genitalia and by allowing previously upregulated central nervous system pathways involved in pain signaling to be downregulated. The goal of microsurgical denervation of the spermatic cord is to alleviate chronic orchialgia while sparing the testicle or preserving both its psychological and physiologic roles.

Introduction Chronic orchialgia is defi ned as intermittent or constant, unilateral or bilateral testicular pain persisting for greater than 3 months [1]. It has various etiologies including vasectomy, inguinal hernia, herniorrhaphy, scrotal surgery, epididymitis, infection, varicocele, trauma, tumor,

intermittent torsion, physical straining, varicocelectomy, back injury, and back surgery. In a substantial percentage of patients, this pain may be idiopathic. Chronic orchialgia adversely affects a man’s quality of life and often presents a challenging management dilemma for urologists. Before seeing a urologist, many patients suffer for years and have often been evaluated by multiple health care providers. Nonsurgical treatments include antibiotics, NSAIDs, antidepressants, anticonvulsants, regional and local nerve blocks, physical therapy, biofeedback, acupuncture, and psychotherapy [2]. Chronic pain research illuminates mechanisms in a variety of conditions including orchialgia. The central and peripheral nervous systems are no longer believed to be static. It is currently recognized that a neuron’s phenotype can change. Nociceptors and their neurons display a phenomenon known as sensitization following repeated stimulation. In the peripheral nervous system, the neurons undergo modulation that results in a decreased threshold for depolarization, increased frequency of response, and a decreased response latency time. Intracellularly, the expression of cascade components and NMDA receptors involved in pain signaling are upregulated. Eventually, they begin to fire spontaneously, resulting in chronic pain [3]. Management of chronic orchialgia should always proceed conservatively. When the aforementioned lessaggressive modalities fail, patients are often willing to undergo surgery for relief. Existing options include epididymectomy, orchiectomy, vasovasostomy, and microsurgical denervation of the spermatic cord (MDSC). Our series of 66 men undergoing MDSC starting in June 1991 includes a total of 82 testicular units with a mean follow-up of 20 months. For all testicular units, postoperative pain relief was complete (0 on a 10-point scale), partial, or unchanged in 58 (71%), 17 (21%), and 7 (8%), respectively [4•]. Complications included two reports of testicular atrophy without hypogonadism and one hydro-

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Expert’s Corner

cele, which resolved spontaneously. There were no reports of impotence, regional hypoesthesia, or hyperesthesia. Other, smaller MDSC series report complete success rates ranging from 76% to 100% [5–8]. We believe MDSC offers select men with chronic orchialgia refractory to conservative management the best chance for pain relief with a low risk of complications.

Patient Evaluation A detailed medical history first focuses on the whole patient, then on orchialgia. Necessary information includes the pain history including duration and etiology (unknown in ~ 40% of our patients); previous genital infection; back injury, pain, or trauma; psychiatric disorders; analgesic use; and prior surgery in the pelvis, inguinal region, or scrotum. Physical examination should evaluate the testicles, vas deferens, epididymis, and vascular plexuses to identify the exact location of the pain. Pain is rated on a scale of 0 to 10. Digital rectal examination evaluates the prostate and rectal tone. If prostatodynia or pain with ejaculation is present, semen or expressed prostatic secretions are cultured. If a history of back pain or trauma is reported, musculoskeletal and neurologic examination of the spine is performed. CT or MRI is ordered if history and physical examination findings are significant. All patients undergo duplex scrotal ultrasonography to exclude structural abnormalities, such as tumor, torsion, varicocele, hydrocele, spermatocele, inguinal hernia, and epididymo-orchitis. Urinalysis is routinely performed. If nonsurgical treatments fail or a reversible cause of the pain is not identified, a spermatic cord block is performed at the pubic tubercle area with 20 mL of 0.5% bupivicaine without epinephrine. Only when temporary complete or partial pain relief (> 50% reduction of pain) is reported should MDSC be offered. About 30% of our chronic orchialgia patients do not respond to the block and are not offered MDSC. This may indicate a pudendalnerve (posterior) source for the pain or the presence of sensitization within the central nervous system. If the patient is a candidate, the risks of the procedure are explained, including failure to alleviate the pain, infection, bleeding, testicular loss, hypogonadism, and infertility.

MDSC Technique The technique of MDSC has been detailed in other publications [2 , 5–8]. The main difference between our technique and others is that we divide the ilioinguinal nerve and now spare the vas deferens in fertile men, only stripping the vasal adventitia, which carries afferents likely to be involved in pain. To start, a low inguinal incision is made, exposing the external inguinal ring. The ilioinguinal nerve is identified and a 2- to 3-cm segment is excised. Following ligation, the proximal end of the nerve is buried under the external

inguinal ring to decrease the risk of neuroma formation. The spermatic cord is then elevated and brought to rest on a five eighths–inch Penrose drain. An operating microscope set at 8 times magnification is brought to the field. The anterior spermatic cord fascia is opened for 3 to 4 cm to expose the cord contents. MicroDoppler ultrasound identifies the location of arterial flow in the testicular, cremasteric, and deferential arteries and branches, which are secured with microvessel loops. The internal spermatic veins are ligated and divided. As many lymphatics as possible are identified and spared; this is thought to prevent hydrocele formation. Electrocautery is used to divide all of the remaining cremasteric musculature and spermatic cord fascia. In men who have not undergone vasectomy, the vas deferens is preserved to prevent epididymal congestion, which is thought to contribute to postvasectomy pain syndrome. The vas is stripped of its fascia-covered outer layer to ablate afferent nerve pathways. In those with prior vasectomy, the vas is divided again to ensure that any neural fibers within and on the vas are destroyed. The cord is placed back into its original position and 10 mL of 0.5% bupivicaine without epinephrine is injected into the wound, which is closed in layers. Before closure, pulsatile flow within the preserved arteries is confi rmed with the micro-Doppler. If poor flow due to spasm is noted, topical papaverine is applied to the vessel surface to encourage vasodilatation.

Discussion As seen in our series and those previously mentioned, up to 97% of patients reported complete success. None of our 58 (71%) patients with complete relief had recurrence of pain. They were followed for a mean of 20 months, suggesting the procedure has durable results. The results and complications reported in other MDSC series are similar. Compared with other surgical treatments for chronic orchialgia, MDSC offers similar or better success rates. Four epididymectomy series report 10%, 24%, 48%, and 100% complete success rates [1,9–11]. We believe epididymectomy should only be performed when chronic pain localizes only to the epididymis. In our experience, if this fails, MDSC may be performed later and has worked. Vasovasostomy for postvasectomy pain syndrome is costly and defeats the original intention of sterility and has variable success rates of 69% to 100% [12–14]. Orchiectomy is a drastic measure. By ablating the testicle, gonadal endocrine function is diminished, and castration may cause psychological consequences. In addition, complete resolution of pain is not guaranteed [1,15].

Conclusions MDSC offers the patient with chronic pain a minimally invasive and efficacious outpatient surgical repair for

Microdenervation of the Spermatic Cord for the Treatment of Chronic Orchialgia

chronic orchialgia that is refractory to conservative management. In our experience, up to 71% of patients are pain-free without compromising the endocrine, reproductive, and psychological roles of the testicle.

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Disclosures No potential conflicts of interest relevant to this article were reported.

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References and Recommended Reading

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Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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Davis BE, Noble MJ, Weigel JW, et al.: Analysis and management of chronic testicular pain. J Urol 1990, 143:936–939. 2. Levine LA, Matkov TG, Lubenow TR: Microsurgical denervation of the spermatic cord: a surgical alternative in the treatment of chronic orchialgia. J Urol 1996, 155:1005–1007. 3. Woolf CJ, Salter MW: Neuronal plasticity: increasing the gain in pain. Science 2000, 288:1765–1769. 4.• Strom KH, Levine LA: Microsurgical denervation of the spermatic cord for chronic orchialgia refractory to medical management [abstract 593]. Presented at the American Urological Association Annual Meeting. Anaheim, CA; May 19–24, 2007. This abstract summarizes the latest information about MDSC.

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