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

26. Chronic Orchialgia: Workup and Management
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Fig. 26.3. Algorithm for evaluation and management of chronic groin and scrotal
content pain.
daily for 10 days) and ceftriaxone 125 mg intramuscularly once. Over
the age of 35, Escherichia coli is a common urinary pathogen that can
cause epididymal infection. E. coli infection can be treated with a course
of quinolones (ciprofloxacin 500 mg orally twice daily or levofloxacin
500 mg orally once daily for 10 days). A 1-month supply of quinolone
therapy can also be considered in combination with NSAIDs for refractory
cases.
Antidepressants used at lower doses for chronic pain work by inhibiting
the reuptake of norepinephrine. A commonly used class of antidepressants
is tricyclics, which include amitriptyline 10–25 mg orally
daily and nortriptyline 10–150 mg orally daily. These medications are
slowly titrated up to therapeutic levels. The use of these medications can
also help the comorbid psychological factors that may contribute to
genital pain. In a study of 48 patients with genital pain and no organic
findings, psychological disorders were diagnosed commonly, including
major depression (27 %), somatization disorder (56 %), and chemical
dependency (27 %) [ 16 ]. It is critical to taper patients off tricyclic antidepressants—they
should never be stopped abruptly.
Anticonvulsants contribute to pain management through their
ability to modulate central calcium channels with chronic use via an
effect on trafficking [ 17 ]. Gabapentin and pregabalin are common
anticonvulsants used for neuropathic pain. We start with gabapentin