Page 8 - Best Practice Report: Canadian Urological Association best practice report on chronic scrotal pain

Jarvi et al

opinion). Nerve blockade as a therapeutic measure should group. Padmore et al studied 57 patients after epididymectomy.
be considered prior to any surgical management, as it may They found a much higher cure rate in epididymectomy per-
predict intervention success (Level 3 evidence, Grade C formed for symptomatic epididymal cysts (76%) vs. epididy-
recommendation). Longer-term nerve blockade modali- mitis (24%); 22% of the patients with epididymitis in this study
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ties are still considered experimental, but early results are further underwent orchiectomy for pain. Davis et al found
promising (Level 4 evidence, Grade D recommendation). that nine out of 10 patients treated with epididymectomy for
CSP required subsequent orchiectomy as a definitive treat-
Surgical management ment. While the current published success rates of epididmy-
12
ectomy specifically for PVPS do appear promising, as well as
When conservative and medical management fail, surgery in selected patients with palpable epididymal pathology (such
may be considered as the next treatment option. Surgical as a painful cyst), it must be made clear to the patient that this
management of patients with CSP should, if possible, be procedure will make reconstruction of the reproductive tract
directed at relieving the underlying causes for pain identified impossible, possibly impacting future fertility.
through the diagnostic evaluation.
Varicocele repair for symptomatic varicoceles (Grade 3C)
Microsurgical vasovasostomy for post-vasectomy pain syndrome (PVPS) Varicoceles are a common finding, with a reported preva-
(Grade 3C) lence of 15% in the general population. Although varico-
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Persistent scrotal pain after vasectomy is a fairly rare compli- celes are asymptomatic in many men, an estimated 10% of
cation. The American Urological Association (AUA) guideline men with varicoceles will have CSP. Due to the prevalence
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on vasectomy states that 1–2% of men undergoing vasectomy of varicoceles in the general population, it is important to
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will develop CSP. Other studies have reported up to 15% assess and rule out any other causes of scrotal pain. Pain
of men reporting new scrotal pain up to seven months after pathogenesis from varicoceles is poorly understood, with
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the vasectomy. The etiology of post-vasectomy pain is still multiple theories, including the dilatation of the pampiniform
poorly understood. Potential theories include epididymal plexus causing compression of neural fibers, tissue ischemia
congestion, perineural fibrosis from scar tissue, inflammation secondary to venous stasis, increased scrotal temperature,
from the leakage of antigenic vasal fluid, or vascular stasis. 57 and oxidative stress in the testicular parenchyma. 69,70
The published evidence on the management of PVPS In patients who have failed conservative and medical
is still limited, with no level 1 data guiding management. management, varicocele repair, regardless of approach,
However, as with the rest of CSP, it is reasonable to attempt has been shown in numerous small series to be effective,
conservative therapies and pharmacological treatment first with reported improvement or complete resolution rates
before any surgical management is proposed. ranging from 80–100%. 68,69,71 Though there are numerous
The literature on vasovasostomy (VV) or vasectomy rever- approaches to varicocele repair, including inguinal, sub-
sal for PVPS comprises of small, single-centre studies. The inguinal, retroperitoneal, embolization and laparoscopic,
concept of VV for PVPS seems to be intuitive. Through rees- these approaches have not been compared. We recommend
tablishing continuity of the reproductive tract, this procedure that if varicocele repair is to be undertaken, a standard vari-
aims to relieve epididymal obstruction, as well as decrease cocelectomy should be performed using the accepted tech-
the leakage of inflammatory vasal fluid from the testicular nique to surgically treat varicoceles for men with infertility.
end. All studies on VV for PVPS have shown that nearly
100% of patients will have improvement in pain scores, with MDSC (Grade 3C)
complete resolution ranging from 50–100%. 58-61 In these MDSC was first reported by Devine and Schellhammer in
studies, all patients underwent microsurgical VVs. 1978 as a means to treat testicular pain of unknown etiol-
ogy. In their initial report comprising of only two patients,
5
Epididymectomy for PVPS and symptomatic epididymal cysts (Grade 3C) they reported a 100% complete resolution of pain in these
Epididymectomy is another treatment for CSP that has been patients. This surgical procedure has increased in popular-
assessed in multiple small series in the literature. The suc- ity over the past decade, with better understanding of the
cess rates for epididymectomy in the setting of PVPS vary in pathophysiology of CSP. Parakattil et al identified abnor-
the literature, ranging from 10% to >90%. 12,62-64 However, the mal Wallerian degeneration in the trifecta nerve complex
success rates for CSP as a whole are less promising. Hori et al of the spermatic cord, suggesting a neuroanatomical basis
evaluated 72 patients undergoing epididymectomy for CSP and for the pain. The purpose of MDSC is to transect the
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compared patients with PVPS vs. non-vasectomy patients. In ilioinguinal nerve and all the nerves of the spermatic cord
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this study, 93% of patients with PVPS had less or no pain post- while preserving the testicular artery and the lymphatics,
epididymectomy, with an overall satisfaction rate of 93% com- thus ablating the afferent neural pathways that may con-
pared to 75% and 62.5%, respectively, in the non-vasectomy tribute to CSP. 23

168 CUAJ • June 2018 • Volume 12, Issue 6