Causes of Pain in the Scrotum and Their Treatment Options
There are multiple causes for both short-term (acute) and long-standing (Chronic0 pain in the testicles and the scrotum. Therefore the causes of the pain need to be diagnosed before deciding the treatment options. Sometimes the cause of the pain can be outside the scrotum, and such causes may be difficult to diagnose and treat.
Sudden or Acute pain in the testis
Acute Epididymitis or Epididymoorchitis: This can be due to Infections affecting the testis and the epididymis. Usually, this is associated with urinary infections. The testicles and the structure called epididymis that comes out of the testis can be very swollen and tender. This condition is called Acute Epididymoorchitis. This needs to be treated with an extended course of antibiotics for 2-4 weeks.
Torsion or Twist of the Testis: The other significant cause of testis pain may be due to twists of the testis that can cut off the blood supply to the testis, and the testis can die. This is common in the teenage years but can occur in any age group. This is due to slight anatomical variation of the extension of the inner layer around the testicle, attaching a bit higher than the normal place above the testicle. This allows the testis to twist on the axis of the bundle. These conditions would require immediate surgical treatment to save the testis. The other testis will also be fixed in the scrotum to prevent future recurrence of the torsion on the other side.
Causes of Long-standing or Chronic Testicular Pain
Various conditions can cause long-standing continuous or intermittent sporadic severe pain in the scrotum and the testicles.
1. Post Vasectomy Pain Syndrome (PVPS)
Are you suffering from [ain in your testicles lasting longer than three months since vasectomy? Then it is highly likely you have post-vasectomy pain syndrome (PVPS). After a vasectomy, some men may experience chronic or long-lasting pain for over three months. This pain can range from mild discomfort to debilitating agony, and individual responses can vary. Approximately one in ten men who undergo a vasectomy may develop chronic testicular pain, with a small percentage experiencing significant distress and requiring surgical treatment.
Potential Causes of Pain in the testis after Vasectomy
Pressure building up in the epididymis. Pain following a vasectomy due to pressure can typically begin soon after the procedure and persist for a prolonged period. Pain may also increase after ejaculation. The epididymis may feel normal but slightly sensitive or tender during a physical examination. The intensity of pain can fluctuate on a daily basis.
Chronic Epididymitis:: It's possible to experience chronic inflammation, granuloma, or scarring in the epididymis after a vasectomy. This is caused by ongoing irritation and pressure from the sperm fluid due to the blockage created by the procedure. As a result, the epididymis may appear swollen and tender and may be mistakenly diagnosed as epididymitis and treated with antibiotics multiple times by GPs or urologists.
Granuloma at the site of vasectomy: A sperm granuloma is a type of inflammatory swelling that typically occurs when sperm leaks from the cut end of the vas that's attached to the testicle. This swelling usually feels like a small pea at the site where the vas was cut and may be sensitive to the touch. While most men don't experience persistent pain due to a granuloma, some may experience chronic pain that can be bothersome.
Retractile Testis: Any painful condition in the scrotum, such as mentioned above, can cause spasms in the cremaster, a sleeve of muscle encircling the bundle called the spermatic cord that contains blood vessels and the vas deferens. The repeated spasm of cremaster can cause pain associated with the upward pull of the testis towards the groin. This is known as a retractile testis. Repeated contractions can make this muscle thicker (hypertrophied), making the spasms even more uncomfortable as time goes on. This is usually characterised by sharp pain during the retractile episodes followed by dull aching pain that may be possibly due to the trauma of the soft tissues around the upper part of the testicle during the retractile episodes. Additionally, other conditions may irritate the nerve that supplies this muscle at a higher level in the groin or up to the spine level.
Neuralgic Pain: The nerve pain is caused by the irritation of the sensory nerves by sperm granuloma or scarring.
2. Chronic infection and inflammation in the epididymis
Acute inflammation or infections in the epididymis can cause scarring and blockage of the epididymis leading the chronic inflammation and thickening of the epididymis. Sometimes the swollen and thickened epididymis can become a source of long-standing pain.
3. Cysts and growths in the epididymis.
Cysts are fluid-filled swellings that usually appear at the top of the epididymis. Generally, cysts do not cause pain unless they get as big as the testicle or more. Some times smaller cysts if located between the testis and epididymis, due to pressure, may become a source of pain.
4. Retractile Testis
This is a painful condition caused by the spasms of muscles called cremasters that tend to pull the testicles up. This is discussed above. men who have not had a vasectomy may also develop this condition due to other causes that trigger the muscle.
5. Longstanding shrunken testis
This can be due to previous infection, surgery, or trauma and can cause chronic testicular pain.
6. Torsion of Testis
Intermittent twists of the testicles or twists of small wart-like swellings (appendices) on the surface of the epididymis or testis (more common in children and teenagers)
7. Testicular Tumours
Rarely, pain can be caused by testicular cancer. Typically, this manifests as a lump within the testicle itself. It is crucial to seek immediate medical attention if a lump is detected within the testicle
8. Other Causes
The soft tissues in the scrotum, including fat, are hardened by infection or trauma. Once, we came across a condition called fat necrosis that causes painful lumps alongside the testicle. The pain settled after the removal of the fat lumps.
The potential options for treatment
By all means, you must try to manage without an operation, and the operation should be the last resort as they are not without risks and uncertainties.
Optimised use of painkillers or getting referred to a pain clinic
Various pain-relieving medications can be tried to manage the pain. The coping mechanisms and responses to the pain can be moderated with the help of a clinical psychologist.
Local Anaesthetic Blocks
Injections of local anaesthetic or steroids in the spermatic cord and around the vas can cause short to long-term relief. This can cause bruises after the treatment, though not other significant risks. This can be tried at the first instance before embarking on surgical treatments.
Operative ( Surgical) Treatments
You may understand now that getting to the bottom of the cause of pain will be challenging. Therefore the decision to go for surgery should not be taken lightly before making all attempts to exhaust other non-operative options for treatment.
1. Procedures to remove the thick and tender epididymis
This will be helpful in removing any trigger spots for pain at the epididymis or vasectomy site. An operation called denervation of the testis may also relieve pain, blocking the nerves and taking the pain sensation from the testis.
2. Microsurgical Vasectomy reversal
This is likely to help if the pressure build-up is the cause of the pain. This is also suitable for men who want to regain their fertility or those who regret their decision about vasectomy and want a sense of returning to 'Normal'. You are aware that your fertility is likely to be regained after reversal, and you will have to resort to other methods of contraception. We offer advanced microsurgery vasectomy reversal. For further information, please click the link below.
3. Addressing any other causes for the pain mentioned above
Other conditions, such as an epididymal cyst or hydrocele, can be treated by surgery. Microsurgical Varicocele Ligation can treat a varicocele. We offer these treatments at Best Life Clinic.
We perform division of the cremaster sleeve of muscle if it is thickened, which may relieve the retractile testis pain.
Most of the time, you will be asked to come for a face-to-face consultation or attend a video consultation for a fee. However, you can get started today by completing the questionnaire below. Even if you haven't had vasectomy reversal before, please complete the relevant details of your pain, including the onset, duration, and nature. You will receive a free summary based on the questionnaire you fill out.