Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

10. Groin Pain Etiology: Spermatic Cord and Testicular Causes
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CPPS. In a cohort of 488 men evaluated for CPPS, 47 % had subjective
symptoms of testicular pain, of whom only 7.5 % had reproducible
tenderness [ 64 ], highlighting the importance of properly classifying
patients with CPPS. The treatment of CPPS is discussed below, but
patients with idiopathic inflammatory epididymitis are often treated
with long- acting NSAIDs and rest [ 30 ]. If pain persists despite conservative
management, surgical options such as microsurgical spermatic
cord neurolysis or epididymectomy are considered.
Lesions of the Epididymis Mass lesions can cause noninflammatory
epi didymal pain, although the majority of these are painless. In a series
of 1000 men undergoing ultrasound for testicular pain or swelling, 24 %
were found to have epididymal cysts [ 65 ]. In a series of men undergoing
ultrasound for infertility, the incidence was 7.6 % [ 45 ]. Spermatocele is
another common cystic epididymal lesion that is usually asymptomatic.
Solid masses of the epididymis are usually benign, with adenomatoid
histology being the most common [ 30 ].
Post-vasectomy Pain Syndrome A small subset of men develop
chronic testicular pain after vasectomy that can be debilitating and
difficult to treat. Post- vasectomy pain syndrome (PVPS) is defined as a
scrotal pain syndrome that follows vasectomy and falls under the second
type of chronic epididymitis as described by Nickel (see Table 10.3 ) [ 2 ].
Pros pective studies have found that almost 15 % of men who had no
scrotal pain before vasectomy have some scrotal discomfort 7 months
post operatively, with 0.9 % having “severe” pain affecting quality of
life [ 66 ]. Overall the incidence of PVPS ranges from 1 to 52 % [ 67 – 70 ].
The pathogenesis of PVPS is unclear; theories include the extravasation
of sperm with resultant sperm granuloma, infection, nerve entrapment,
and testicular engorgement from sperm due to long-standing obstruction
[ 67 , 71 ]. Mechanical obstruction may be a significant contributor, as
Moss et al. found closed- ended vasectomies have a threefold higher rate
of PVPS than open-ended vasectomies [ 72 ]. Conservative management
with NSAIDs, scrotal support, and limitations in activity is first choice.
While many respond to conservative measures, often further intervention
is needed. Spermatic cord blocks can provide relief of the pain, and
definitive interventions may include microsurgical spermatic cord denervation,
vasectomy reversal, epididymectomy, or orchiectomy [ 73 ].
Post-inguinal Herniorrhaphy Testicular Pain Similar to the postvasectomy
pain syndrome, patients can develop post- inguinal hernior-