Canadian Urological Association best practice report on chronic scrotal pain

Chronic scrotal pain (CSP) is poorly understood, with relatively limited information published on the incidence, natural history, or therapies for this chronic condition. Estimates of the frequency of CSP range from 0.4–4.75%, but these estimates are based on studies of CSP within specific groups of men and may not reflect the true incidence of CSP among the general population of men.1-3 Unfortunately, this chronic condition is frequently extremely frustrating for both patients and clinicians, with patients often seeing multiple clinicians to seek treatment; one study found that the average CSP patient will have seen a mean of 4.5 urologists for the condition and have undergone an average of 7.2 diagnostic investigations.4 Described as “chronic orchialgia”5 or testicular pain syndrome,6 it is now recognized that scrotal pain may arise not only from the testicles, but can involve adjacent paratesticular structures, such as the epididymis and vas deferens, or pain may be referred from conditions involving the spermatic cord or the retroperitoneum. Therefore, the broader term chronic scrotal pain is more descriptive when referring to this condition.1,7 Similar to other chronic pain conditions, CSP has been shown to negatively impact the affected individual’s quality of life. More than 50% of patients with CSP report limitations to their daily activities, limited ability to work, and decreased sexual activity.8 Depression is also frequently associated with CSP, with 40% of patients with CSP reporting depressive symptoms more than half of the time.8 In a study of 48 men diagnosed with CSP and no organic findings, Schover et al found that many of these patients were diagnosed with psychological disorders, including somatization disorder in 50% and depression in 27%.9 Up to a third of these patients were socially isolated, and 18% had an emotional event occurrence around the onset of pain. The concept of chronic pain has now shifted from a biomedical model to a biopsychosocial one. Studies have shown that the level of social support, expectation of pain, interference with work or other activities, and past memories all affect an individual’s experience of pain.10 CSP is often debilitating and is associated with depression, anxiety, sexual dysfunction, and overall decreased quality of life.11 Currently, there is a lack of widely accepted published guidelines for the evaluation and management of men presenting with CSP. Such guidelines will provide a framework to help support clinicians struggling to manage men with this challenging condition. The purpose of this document is to thoroughly review the current literature on CSP and provide a Canadian Urological Association (CUA) best practice report to help direct the evaluation and management of men presenting with this often debilitating condition.