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

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primary sites (trifecta nerve complex) of highest nerve density are (in
decreasing order): cremasteric muscle fibers, perivasal tissue and vasal
sheath, and posterior peri-arterial/lipomatous tissue [ 13 ].
Evaluation
Workup of CGSCP begins with a thorough history and physical
examination. The characteristics of pain, including onset, duration, and
severity, are questioned. Pain is rated using the visual analog scale and
externally validated pain impact questionnaire (PIQ-6, Quality-Metrics
Inc., Lincoln, RI, USA).
Physical examination focuses on the groin and testicle in the attempt
to identify any anatomic causes of the pain, including hernia, varicocele,
testicular masses, epididymal cysts, and granulomas from previous
vasectomy. All possible causes such as ureteral stones, infection (orchitis
or epididymitis), or back problems (lumbar disk hernia) need to be ruled
out. Urine analysis, scrotal ultrasonography, abdominal computerized
tomography (CT), and spinal magnetic resonance imaging (MRI) should
be performed when indicated. Scrotal ultrasound is not necessary when
physical examination and urine analyses are normal in patients with
chronic scrotal pain. Van Haarst et al. evaluated scrotal ultrasonography
imaging of 111 chronic scrotal pain patients with normal physical examination
and urine analyses and found 12 epididymal cysts less than 0.5 cm
and three subclinical varicocele but no clinical significant abnormalities
[ 14 ]. Since a significant percentage of CGSCP is idiopathic, patients
often have completely negative evaluations. Treatment for these patients
is initiated using a structured algorithm (Fig. 26.3 ).
Medical Treatment
In the absence of any acute findings that require surgical intervention,
conservative medical therapy is a first-line treatment [ 15 ]. One month of
nonsteroidal anti-inflammatory drugs (NSAIDs) is recommended [ 1 ].
We usually start with meloxicam 7.5 mg daily or high-dose ibuprofen
600 mg orally three times daily. Newer low-dose NSAIDs such as
Zorvolex 35 mg BID-TID can be used to decrease side effect potential.
Sexually transmitted infection with gonorrhea or chlamydia should
be considered in men between the ages of 15–35. This is usually treated
with azithromycin 1 g orally once (or doxycycline 100 mg orally twice