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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Surgical Management: Chronic Pain
Conservative measures such as rest, scrotal support, and sitz baths
should always be attempted first for chronic groin pain, with surgery
reserved for those who have persistent refractory pain that significantly
diminishes their quality of life. Medical therapy includes antibiotics,
anti-inflammatory agents, phytotherapy, anxiolytics, narcotics, acupuncture,
and injection therapy with steroids and anesthetics [ 40 ]. A consultation
with the pain service can be helpful before surgical intervention is
considered.
Microsurgical Spermatic Cord Neurolysis Microsurgical denervation
was first described in 1978 by Devine and Schellhammer [ 91 ]. Branches
from the ilioinguinal nerve, the genital branch of the genitofemoral
nerve, and autonomic fibers all merge at the spermatic cord, making it
amenable to neurolysis.
Microsurgical denervation is a primary surgical option for men with
chronic testicular pain in the absence of identifiable pathology. Potential
candidates should undergo spermatic cord blocks preoperatively with
demonstrated improvement in pain. If there is no pain relief with the
nerve blocks, neurolysis may not be an appropriate therapy and other
options should be considered.
Heidenreich et al. showed that 97 % of men who had complete relief
of pain with preoperative nerve blocks were pain free at a mean of 34
months after surgery [ 8 ]. In another series, 71 % had complete pain
relief and 17 % had partial relief [ 92 ]. Overall, a review of the literature
including more than 600 testicular units demonstrated 82 % pain-free
rate after microsurgical spermatic cord neurolysis [ 93 ].
The operation involves identification of the external inguinal ring
where a 3 cm transverse incision is made. The spermatic cord is isolated
and delivered into the field. The external and internal spermatic fasciae
are incised. The operating microscope is used to identify the vas bundle.
This is preserved. The testicular artery and several lymphatic channels
are preserved. All other veins and nerves are ligated or clipped. Some
authors advocate dividing the periadventitial tissue of the testicular
artery to achieve further denervation, but the success rate is comparable
and this step may increase the risk of arterial injury [ 8 ].
Vasovasostomy Microsurgical vasovasostomy (or vasoepididymostomy )
is used for two primary indications: reversal of sterility or relief of intractable
testicular pain after vasectomy (Fig. 10.3 ) [94]. Some cases of PVPS are