Chronic testicular pain or groin pain is initially managed using conservative therapies. A urologic workup is usually completed to ensure that there is no other contributing factor to this pain (this is usually done before patients come to see us by their primary urologists). If this workup is negative, a trial of oral anti-inflammatory, antibiotics, acupuncture or pelvic floor rehabilitation may be utilized. If any of these techniques fail, then we have developed some unique treatment options that may offer relief.
The PUR Clinic has developed a unique classification system to try to better measure or assess the type of pain that patients are experiencing, since each patient is unique in terms of the type of pain they may experience. Currently, we proceed straight to these treatment options based on patient symptoms because of the high success rates in eliminating or significantly reducing pain compared to the lower success rates with conservative treatment options:
Our recent peer reviewed article in the Journal of Urology describing the Trifecta Nerve Distribution
Steps We Follow to Treat Testicular Pain
1. Mapped Segmental Spermatic Cord block
A precise minimally invasive delivery of local anesthetics and anti-inflammatory agents at predefined locations along the spermatic cord to assess if specific nerve fiber de-activation provides pain relief for the patient. We use a trifecta nerve based targeting template (based on our previously mentioned nerve mapping work). If this resolves the pain, then the pain is likely to be of neurologic origin due to hypersensitive pain nerve fibers.
The cord block usually only provides temporary relief (hours, days or weeks, depending on the individual patient and their baseline pain characteristics). A patient who responds to the cord block (even transiently) is likely to be a good candidate for robotic targeted neurolysis or denervation of the spermatic cord, which will usually provide permanent relief. The nerve distribution is quite complex in the cord, and we believe that because we may miss some of the critical nerves with a cord block, we may be able to do a more precise and more targeted lysis or ligation with robotic neurolysis. This may explain why many patients who do not respond to the block may respond to targeted denervation or neurolysis.
If patients do not want to jump into denervation or neurolysis, we may try a series of three cord blocks spaced a few weeks apart to see if we get a more durable response. A recent review of a few hundred cord block cases revealed that the median response to one block was about 1 month, and the median response to a series of three sequential blocks was about 3 months (there were a few patients who had a response that went to about 1 year, but most patients tend to eventually relapse with their pain after cord blocks).
2. Targeted Robotic assisted targeted microsurgical neurolysis or denervation of the spermatic cord (or genito-femoral & ilio-inguinal nerves in women)
We perform a highly specialized, targeted, robotic assisted microsurgical dissection of the trifecta nerve fiber complex in the spermatic cord that we think is responsible for the pain, and ligate them to hopefully achieve permanent pain relief. This technique involves a small 1-2 cm skin incision in the groin and then dissection through the spermatic cord in a minimally invasive manner. We are the leading center in the development of this technique and have achieved a complete or partial resolution of pain in up to 85% of over 600 patients so far (since 2008) based on a validated pain impact score (the PIQ-6 score). We have the largest case experience in the world and continue to evolve our technique to achieve better outcomes.
This procedure is performed with real-time intra-operative Doppler identification and protection of the testicular arteries to prevent any potential testicular atrophy or injury. The robotic platform provides unparalleled 3 dimensional high definition visualization, refined surgical instrument handling (removal of any tremor) and the ability of the surgeon to utilize multiple instruments simultaneously (due to the additional robotic arm) to provide enhanced efficiency. We have also incorporated some modifications to the technique to further minimize any risks to the patient.
- High pressure Hydrodissection of the vas deferens: This allows us to further ligate the fine reticular nerve fiber complex (part of the trifecta) without damaging any of the fine blood vessels on the vas deferens surface (vasa vasorum)
- Bio-Inert Biowrap around the spermatic cord: After completion of the targeted denervation, we gently wrap the spermatic cord with a bio-inert biowrap to reduce the chance of neuroma formation or scarring in the cord.
- CO2 laser ablation to perform the targeted denervation: The denervation or ligation of the trifecta nerve complex is performed with a novel CO2 laser device to ensure the most precise ligation of the nerves possible to further minimize the risk of neuroma formation.
We focus greatly on the targeted denervation technique to ensure that patients have minimal side effects and should not have any decreased sensation in the testicle, and no effect on their erections and sexual function. The goal is simply to relieve the patient from the chronic testicular and/or groin pain while minimizing any loss of other functionality.
3. Targeted Peri-Spermatic Cord and/or Ilioinguinal Nerve Micro-Cryoablation
In 15% of patients, despite targeted denervation of the trifecta complex in the cord, they may still have persistent pain or pain that returns after a short while after the surgery. There are also patients that present with groin or lower abdominal pain (male & female patients) without testicular pain. For these types of cases, we tend to perform targeted nerve blocks to the genito-femoral and ilio-inguinal nerves. If the patients respond to these blocks, then we may try targeted peri-spermatic cord and/or ilioinguinal micro-cryoablation.
Cryo-ablation has been used successfully in the past for peripheral nerve pain syndromes, but the older techniques utilized much larger cryo probes that required more extensive and open exposure techniques. We now utilize the world’s smallest micro-cryoablation probes to provide a minimally invasive technique to perform ultrasound guided targeted micro-cryoablation of the genitofemoral and/or ilioinguinal nerves. The image to the right (or below on mobile phones) illustrates the technique. We are the first center offering this procedure and are the official credentialing and training site for surgeons who may want to perform this procedure. Currently, we are the only center performing this procedure. We usually get about a 70-75% success rate in significantly reducing pain in patients who undergo this procedure.
4. Targeted peri-spermatic cord and/or ilioinguinal nerve botox ablation
If patients fail denervation (15%) and also fail micro-cryoablation (25-30% of these denervation failure patients), then we may try targeted peri-spermatic cord and/or ilioinguinal nerve botox ablation. Botox ablation has been used for chronic pain nerve syndromes, and we are now utilizing this technique in patients with complex pain that does not seem to respond to the above mentioned techniques.
We perform this only if the patient has had a response to a previous targeted block. If the block seemed to give them some temporary relief in pain, then they may be a candidate for botox ablation. We are currently getting about a 60-65% success rate in significantly reducing pain in patients who undergo this procedure, but are still not sure of the long-term durability of this technique. It is likely that patients may require one or two more of these blocks after a few months. We tend to try denervation prior to botox or micro-cryoablation, since these ablative techniques may create some scarring around the cord that makes future denervation more challenging.
5. Robotic assisted microsurgical vasectomy reversal with Biowrap
In a small percentage of men who have previously undergone a vasectomy, there may be chronic groin or testicular pain. This pain can range from mild irritation to debilitating pain that requires chronic pain medication use. In some of these men with specific findings of episodic pain, especially after ejaculation, or episodic pressure sensation, robotic assisted vasectomy reversal may be a treatment option.
This modality is utilized if the patient does not respond to a cord block. Successful relief of pain may be achieved in up to 69% of patients undergoing microsurgical vasectomy reversal from prior publications. In our cohort of patients undergoing robotic vasectomy reversal for pain, we have achieved a higher pain resolution rate (80-90%). More recently, we have incorporated the use of a bio-inert biowrap around the vasal anastomosis to try to further reduce granuloma formation or scarring at the reversal sites (based on prior animal studies that have shown an advantage). Currently, we achieve a 90-95% success rate in significantly reducing post-vasectomy congestive type pain after this type of reversal.
6. Robotic Assisted Abdominal (Single Port or Multi-Port) Neurolysis or Denervation of the genitofemoral and inferior hypogastric nerves
This is a unique procedure for patients with chronic groin pain, lower abdominal pain, pelvic pain (female patients), phantom pain after orchiectomy (testicle removal) or intractable autonomic dysreflexia (in spinal cord injury patients). This option may be considered in patients who have failed more conservative approaches or in patients who have failed some of the previously mentioned treatments options (above). The success rates are in the 70% range (in our series of over 50 cases). However, we have had one or two patients who have had an increase in pain or a redistribution of the pain to the leg or lower extremity areas; thus, this option is only considered in specific circumstances when other options have failed.