Posts Tagged ‘pain’

Chronic Testes Pain

March 7, 2018

Andrew Siegel MD    3/7/2018

New Jersey is shut down because of the impending Nor’easter, surgery and office hours are cancelled, so I have plenty of free time and am going to post this entry today rather than on Saturday morning.

Orchialgia is medical-speak for chronic testes (ball) pain, defined as constant or intermittent pain perceived in the testicles, lasting for 3 or more months and interfering with one’s quality of life.  It is a not uncommon problem of men of all ages, but is more frequently seen in young adults.  It certainly keeps us busy in the office…some morning sessions seem like “ball clinics”!

Testes 101

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Image above, public domain from Wikipedia

The testes are paired, oval-shaped organs that are housed in the scrotal sac. They have two functions, testosterone and sperm production.  Encased within the tough and protective cover of the testes (tunica albuginea) are tiny tubes called seminiferous tubules which make sperm cells.  The testes also contain specialized cells called Leydig cells that produce testosterone.  Sperm from the testes travels to the epididymis for storage and maturation. The epididymis empties into the vas deferens, which conducts sperm to the ejaculatory ducts.

The testes are suspended in the scrotal sac via the spermatic cord, a “rope” of tissue containing connective tissue, the vas deferens, the testes arteries, veins, lymphatics, and nerves. The spermatic cord is enveloped by tissues that are extensions of the connective tissue coverings of three of the abdominal core muscles. The most important of these coverings surrounding the spermatic cord is the cremaster muscle, which elevates the testes in a northern direction when it contracts.

The scrotal sac has several roles, packaging the testes as well as aiding in their function by regulating their temperature. For optimal sperm production, the testes need to be a few degrees cooler than core temperature.  The dartos muscle within the scrotal wall relaxes or contracts depending on the ambient temperature, allowing the testes to elevate or descend to help maintain this optimal temperature. Under conditions of cold exposure, the dartos contracts, causing the scrotal skin to wrinkle and to bring the testicles closer to the body.  When exposed to heat, dartos relaxation allows the testicles to descend and the scrotal skin to smoothen.

Good news/bad news:

The good news about the testes location dangling between one’s legs is is ready and easy access for examination, unlike the female counterpart (ovaries), which are within the abdomen.  This is one reason why testes cancer is so much easier to diagnose at an early stage than ovarian cancer.

The bad news is that their precarious location dangling between one’s legs as well as their delicate packaging in the thin sac makes them subject to trauma and injury.

Chronic orchialgia

Chronic testes pain can be caused by numerous different conditions and it is important to rule out the following possibilities:

  • Infection: An infection of the testes (orchitis), epididymis (epididymitis), both (epididymo-orchitis), or the spermatic cord (funiculitis). Infections can be bacterial, viral, and at times inflammatory without an actual infection.
  • Tumor: A benign or malignant mass of the testes or epididymis.
  • Groin hernia: A prolapse of intra-abdominal contents through a weakness in the connective tissue support of the groin.
  • Torsion: A twist of the testes or one of the testes or epididymal appendages.
  • Hydrocele: An excess fluid collection in the sac surrounding the testes.
  • Spermatocele: A cyst resulting from a blockage of one of the sperm ducts within the epididymis.
  • Varicocele: Varicose veins of the spermatic cord.
  • Trauma: Injury.
  • Prior operations: Groin hernias are most commonly associated with chronic testes pain; less commonly, vasectomies and any other type of groin or pelvic surgery.
  • Referred pain: Pain perceived in the testes, but originating elsewhere, e.g., a kidney stone that has dropped into the ureter, or a lower spine issue affecting the nerves to the testes.
  • Tendonitis: There are numerous muscles with tendons that insert into the pubic bone region that can be subject to injury and inflammation.
  • Pelvic floor muscle tension myalgia: Excessive muscle tension in these muscles can cause pelvic pain, including pain in the testes.
  • Idiopathic: This fancy medical term means that we are clueless about the origin of the pain. Unfortunately, many men have idiopathic orchialgia, a distressing and frustrating experience for both patient and urologist.

Evaluation

The evaluation of the patient with chronic testes pain includes a detailed history, a careful examination of the scrotal contents, groin and prostate, if necessary, as well as a urinalysis and possibly urine culture. It is helpful to obtain an ultrasound of the scrotum, a study which utilizes sound waves to image the testicle and epididymis. On occasion, it is warranted to obtain imaging studies of the upper urinary tract and pelvis and possibly a CT or MRI of the spine if there is back or hip pain.

Management

The management of chronic testis pain is directed at the underlying cause, although unfortunately this cannot always be precisely determined. Often, a course of antibiotics may prove helpful even if the physical findings are indeterminate.  Anti-inflammatory medications such as Advil and ibuprofen are often useful in the short-term management. Supportive, elastic jockey shorts as well as local application of a heating pad can be helpful. At times, amitriptyline or Neurontin can be helpful for neurologically-derived pain.  If the source of the pain is felt to be tension myalgia, referral to a pelvic floor physical therapist can be beneficial.  A referral to a pain specialist, typically an anesthesiologist who focuses on this discipline, can be advantageous.

An injection of a local anesthetic into the spermatic cord (spermatic cord block) can be a useful diagnostic test and a means of alleviating the pain.  If spermatic cord block proves successful in relieving the pain, it may be necessary to surgically denervate the spermatic cord, a procedure in which the nerve fibers in the spermatic cord are divided.  Under extremely rare circumstances, removal of the epididymis or the testicle is necessary. Often chronic testis pain remains elusive with the source undetermined and is thought to be similar to other chronic inflammatory conditions.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

 

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Peyronie’s Disease: What You Need To Know

December 28, 2012

Andrew Siegel. MD    Blog # 88

Peyronie’s Disease   is an inflammatory condition of the penis that causes scarring of the sheath surrounding the paired erectile cylinders within the penis.  As a result of this scarring, when an erection occurs, there is asymmetrical expansion of these erectile cylinders resulting in a penile curvature/angulation.  Peyronie’s causes a deformed and often uncomfortable erection that can dramatically interfere with a male’s sexual health.

Scar formation on the sheath of the erectile cylinders can cause pain with erections; penile curvature during erections; the presence of a penile scar or “plaque” that can be felt as a hard lump under the skin; a visual indentation of the penis described as an hour-glass deformity; and failure of the erectile bodies to properly fill with blood, causing erections of poor rigidity. Penile pain, curvature/angulation, and poor expansion of the erectile cylinders collectively can contribute to difficulty in having a functional and anatomically correct rigid erection suitable for satisfactory intercourse. The curvature can range from a very minor, barely noticeable deviation to a deformity that requires “acrobatics” to achieve vaginal penetration to an erection that is so angulated that intercourse is physically impossible.  The angulation can occur in any direction and sometimes involves more than one angle, depending on the number, location and extent of the scarring.

 

The angulation results from the scarring of the sheath of the erectile cylinders that, upon engorgement with blood, expand in an asymmetrical fashion. This situation is analogous to placing a piece of cellophane tape on a child’s balloon and then inflating it—where the tape (scar) is, the balloon cannot expand properly, resulting in an angulation at the point of the tape placement.

The prevalence of Peyronie’s is roughly 5% of the male population with a mean age of 57 years old. The underlying cause of Peyronie’s is unclear, but is suspected to be penile trauma, perhaps associated with vigorous sexual intercourse. The acute phase is characterized by painful erections and an evolving scar, curvature and deformity. The chronic phase that typically occurs a year or so after initial onset is characterized by absence of pain, stable deformity, and possible erectile dysfunction. Peyronie’s regresses spontaneously in about 15% of men, progresses in 40% of untreated men, and remains stable in 45% of men. Many men—understandably so—become very self-conscious about the appearance of their penis and the limitations it causes, and they avoid sex entirely.

Various treatment options include oral medications, topical agents, injections, shock wave therapy, and surgery.  Upon initial diagnosis, most men are started on oral Vitamin E, 400 IU daily, as this has the potential to soften the scar tissue causing the plaque. Unfortunately, however, none of the non-surgical options have proven to be very effective, because the essence of the issue is scar tissue in a very bad location.   This scarring sabotages the ability to obtain a straight and rigid erection. Erectile dysfunction can be managed with one of the oral E.D. medications including Viagra, Levitra, or Cialis.

If there is no response to conservative management of erectile dysfunction, a penile implant may be appropriate—this can manage the dual problems of erectile dysfunction and penile angulation. If erections are adequate, but angulation precludes intercourse, options include procedures that attempt to neutralize the angulation effect of the plaque by doing a nip and tuck opposite the plaque in an effort to make expansion more symmetrical.  Although this technique is effective in improving the angulation, it does so at the cost of some penile shortening, and I have yet to find a man who is pleased with losing penile length. Other more complex procedures involve incising or removing the scar tissue and using grafting material to replace the tissue defect.

Bottom Line: When scar tissue is only an anatomic consideration but not a functional consideration, it may be cosmetically unappealing, but is actually not such a bad situation.  However, when scar tissue occurs on an area of the body that moves, expands or acts as a conduit, it affects form as well as function, which is not a good thing. Thus a scarred elbow can impact mobility of the joint, scarred lungs can disturb breathing dynamics, a scarred bile duct can cause jaundice and scarred erectile cylinders can cause Peyronie’s disease. Unfortunately, it comes down to scar tissue in a bad place.

Resources:

www.peyroniesassociation.org

www.askaboutthecurve.com

www.menshealthPD.com

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.

Kidney Stones…Ouch!

October 19, 2012

Andrew Siegel, M.D.   Blog # 80

 

I have chosen kidney stones as a topic since they are a very prevalent problem that I treat on an everyday basis, and a condition often related to our dietary habits, the quantity of fluids that we drink, and our weight status.

If you have ever suffered with a kidney stone, you truly know what excruciating pain is.  Many women who have experienced both passage of a kidney stone and natural childbirth without any anesthesia will report that the childbirth was the less painful of the two!

Stones are a common condition that has occurred in humans since ancient times; kidney stones have even been found in an Egyptian mummy dated 7000 years old.   The good news about stones is that most of them will pass spontaneously without the necessity for surgical intervention. The other welcome news is that if surgery is required, it is minimally invasive—open surgery for kidney stones has virtually gone by the wayside.

Kidney stones form when minerals that are normally dissolved in the urine precipitate out of their dissolved state to form solid crystals. This crystal formation often occurs after meals or during periods of dehydration. The lion’s share of kidney stones manifest themselves during sleep, at a time of maximal dehydration.  Dehydration is also why kidney stones occur much more commonly during hot summer days than during the winter. This past summer—one of the hottest on record—kept urologists very busy in terms of caring for patients with kidney stones.   Anything that promotes dehydration can help bring upon a stone—including exercise, saunas, hot yoga, diarrhea, vomiting, being on bowel prep for colonoscopy, etc.

In addition to dehydration, another factor that can contribute to kidney stone formation is excessive intake of certain vitamins. The biggest culprit is Vitamin C, also known as ascorbic acid.   When metabolized by the body, Vitamin C is converted into oxalate, one of the components of calcium oxalate stones, the most common variety of stone.  The problem is that vitamin C is a water-soluble vitamin, so any excessive intake is not stored in the body but appears in the urine in the form of oxalate. Additionally, excessive dietary protein intake, fat intake, and sodium are all associated with an increased risk for kidney stones. Having inflammatory bowel disease or previous intestinal surgery can also increase the risk for stones.     Urinary infections with certain bacteria can promote stone formation. Having a parathyroid issue and high circulating calcium levels is another cause of kidney stones.  Obesity is also a risk factor for kidney stones. Some stones have a genetic basis, with a tendency to affect many family members.  My uncle is currently plagued with a stone lodged in his ureter and is scheduled for stone surgery on Monday, and both my father and brother have passed stones.  What does that bode for me?  So far I have been lucky.

A kidney stone starts out as a tiny sand particle that grows as the “grain” is bathed in urine that contains minerals.   These minerals are deposited and coalesce around the grain.  They can grow to a very variable extent so that when they start causing symptoms they may range from being only a few millimeters in diameter to filling the entire kidney.

Some stones are “silent” because they cause no symptoms and are discovered when imaging studies are done for other reasons.  However, most stones cause severe pain known as colic. Colicky pain is often intermittent, originating in the flank area and radiating down towards the groin.  It often causes an inability to get comfortable in any position, and is associated with sweating, nausea, and vomiting. Kidney stones can also cause blood in the urine, sometimes visible and, at other times, only on a microscopic basis. When a stone moves into the ureter (the tube running from the kidney to the bladder), it can become impacted and block the flow of urine. Stones can sometimes cause lower urinary tract symptoms such as urgency and frequency, particularly when the stone approaches the very terminal part of the ureter that is actually tunneled through the wall of the bladder.

Kidney stones are usually any easy diagnosis to make, based upon their rather classical presentation, although on occasion, a stone causes no symptoms whatsoever and is picked up incidentally on an imaging study such as an ultrasound, a CAT scan, or an MRI.   The imaging study of choice for evaluating a kidney stone is an unenhanced CAT scan (without contrast).   A plain x-ray of the abdomen is very useful for stones that contain calcium, and thus are readily visible on an x-ray.

Most stones will pass spontaneously without intervention given enough time.   Conservative management involves hydration, analgesics and the use of a class of medications known as alpha-blockers that can help facilitate stone passage by relaxing the ureteral smooth muscle.   As long as the pain is manageable and there is progressive movement of the stone seen on imaging studies, conservative management can continue to be an option.  Intervention is mandated under the following circumstances: intolerable pain; refractory nausea and vomiting with dehydration; larger stones that are not likely to pass; failure of a stone to pass after a reasonable amount of time; significant obstruction of the kidney; a high fever from a kidney infection that does not respond to antibiotics; a solitary kidney; and certain occupations that cannot risk impaired functions such as an airline pilot.

There are a number of minimally invasive means of treating kidney stones depending upon the size of the stone, its location, and the degree of obstruction of the urinary tract.  Gone are the days when treating a kidney stone required a painful incision and a prolonged stay in the hospital.  Most kidney stones now are managed on an ambulatory basis. Shockwave lithotripsy is commonly used to treat stones in the kidney or upper ureter.  Typically done under intravenous sedation, shockwave lithotripsy uses shockwaves directed at the kidney stone via x-ray guidance to fragment the stones into pieces that are small enough so that they then can then pass down the ureter, into the bladder and out the urethra with the act of urinating.  Another means of managing stones, particularly amenable to stones in the lower ureter but also applicable to any stone, is ureteroscopy and laser lithotripsy.  This procedure is done under general anesthesia. A narrow lighted instrument known as a ureteroscope is passed up the ureter to visualize the stone under direct vision.  A laser fiber is then utilized to break the stone into tiny particles.  The largest fragments are removed using a special basket. A ureteral stent is often left in place after this procedure to allow the ureter to heal as well as to prevent obstruction of the kidney.

You are at high risk for kidney stones if you:

  • Don’t drink enough fluids
  • Have an occupation that requires working in hot environments, such as a chef
  • Exercise strenuously without maintaining adequate hydration
  • Are a male, since the male to female ratio of kidney stone incidence is 3:1
  • Had a previous kidney stone, since about 50% of people who have a stone will experience a recurrence
  • Have a family history of kidney stones
  • Have a urinary tract obstruction
  • Have an excessive intake of oxalate, calcium, salt, protein and fat
  • Take excessive amounts of vitamin C, A, and D
  • Have an intestinal malabsorption
  • Have gout
  • Have parathyroid disease

The key to preventing kidney stones is to stay well hydrated, particularly when exposed to hot environments or when exercising for prolonged periods of time. It is also important to avoid overdoing it with certain vitamins—particularly vitamin C—a major risk factor for kidney stones.  The two biggest risk factors for kidney stones are, in fact, dehydration and excessive intake of vitamin C. Chances are that if you have a healthy diet, you have more than adequate intake of vitamin C and any extra is potentially dangerous. A good sign of adequate hydration is the color of your urine: the urine of a well-hydrated person will look light in color like lemonade, whereas the urine of a dehydrated person will look like apple juice.

So drink up, particularly on hot days…and eat an orange instead of popping a vitamin C supplement…your kidneys will thank you!

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every Saturday morning.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts by email. Please avail yourself of these educational materials and share them with your friends and family.

For a nice booklet on kidney stones in PDF, go to http://www.BergenUrological.com and click on patient education and then on ABCs of Kidney Stones