Introduction

Chronic orchialgia, also known as chronic scrotal pain, leads to approximately 5% of visits to urology clinics.1 It is defined as intermittent or constant unilateral or bilateral testicle or scrotal pain lasting for at least 3 months.2 This condition can significantly impair quality of life and can be associated with various etiologies, including infection, tumor, inguinal hernia, hydrocele, spermatocele, varicocele, referred pain, trauma, and previous operations such as herniography, vasectomy, or other scrotal procedures.3 However, up to 50% of cases have an unknown etiology, complicating the diagnostic and treatment processes.4,5

Phantom orchialgia, or phantom testiclular pain, is a type of neuropathic pain that occurs after orchiectomy (surgical removal of 1 or both testicles) and is reported in about 25% of post-orchiectomy patients. This prevalence is even higher in patients who had pain prior to surgery.6 The phenomenon is thought to be similar to phantom limb pain and is believed to be caused by the brain’s continued perception of a testicle that is no longer present. It is hypothesized that the nervous system retains a “map” of the absent testicle, leading to the sensation of pain despite its removal.

Case Report

A 29-year-old caucasian male veteran sought care in a VA chiropractic clinic complaining of low back pain and left phantom testicular pain. He rated his pain at 4/10 on a verbal analog scale and scored a quadruple visual analog score of 56.7% and a Bournemouth back score of 28.

He described a 7-year history of low back pain related to his military service. While working on an aircraft carrier, he noticed the onset of low back pain, which he attributed to the physical demands of his job. Over time, this pain extended to his left lower extremity. He sought physical therapy and chiropractic care, which provided significant relief for both his low back and lower extremity pain.

The testicular pain had been present for approximately 2 years. He had undergone a vasectomy. Approximately 3 months after the vasectomy, he developed left testicular pain. He was subsequently diagnosed with testicular cancer and underwent a left orchiectomy coupled with the removal of 36 lymph nodes from the left pelvis and lumbar spine. Despite these interventions, his left testicular pain persisted.

Exam findings showed normal thoracolumbar flexion with thoracolumbar junction pain, decreased extension, normal lateral bending and decreased thoracolumbar rotation with stiffness noted. He had a positive bilateral straight leg raise (SLR) test, indicating low back pain with sciatic distribution. The bilateral Patrick’s test was negative, while the right Kemp’s test was positive, producing ipsilateral low back pain. Pain was elicited with palpation of the left greater than right psoas (moderate to severe), the thoracolumbar junction (mild) and the left gluteals and piriformis (moderate). Joint dysfunction was noted in the left sacroiliac joint, L2 and T11 motion units and in the left femoroacetabular joint. Contracture of the left greater than right psoas was seen. He was diagnosed with lumbago and left sciatica myalgia of the psoas and piriformis and phantom orchialgia with history of left orchiectomy.

He was treated with high-velocity low-amplitude spinal manipulation and myofascial release of the bilateral iliopsoas. He wa shon and supervised in the performance of iliopsoas stretches. An initial trial of care of 4 weekly visits was scheduled and commenced 44 days later due to clinic access. The pain steadily decreased over the initial trial to 1/10 and the QVAS decreased to 26.7% (a 53% improvement), while the BBQ decreased to 13 (a 54% improvement). He was instructed in kettlebell assisted self release of the iliopsoas, which he found more effective than the stretches.

A continuation of care was offered, with a frequency of 1 visit every other week for 8 weeks. There was a 2-month lapse in care between initial trial and continuation and he did experience increased pain back to 4/10. Improvement of that visit lasted 21 days until the next visit, with pain remaining at 1/10. Due to scheduling conflicts his treatments were delayed to monthly for approximately 6 months, instead of every other week. However, outcome measures remained stabilized despite a few episodes of increased pain in right hip flexor and low back due to intense increases in activity (hunting trips, playing pool basketball, etc.). His orchialgia symptoms have remained absent throughout continued treatment.

Discussion

The pain originating in the testis and epididymis is mediated by both autonomic and somatic fibers accompanying the internal spermatic vessels. These fibers are carried in the genital branch of the genitofemoral nerve and the ilioinguinal nerve. The autonomic supply from the testis is distributed to the pre-sacral ganglia of T10-12 segments, whereas fibers from the epididymis are distinct and are distributed to T10-L1 segments. The somatic fibers from the parietal and visceral layers of the tunica vaginalis and cremaster muscle are carried by the genital branch of the genitofemoral nerve to L1-2.2 There may also be an alternative autonomic pathway for testicular pain.7–9

The psoas muscle has its origin on the vertebral bodies, discs and transverse processes of the 12th thoracic vertebra and the first 4 lumbar vertebra.10 The iliopsoas also refers pain to the anterior groin area.11 This makes the iliopsoas a potential cause for scrotal pain.

The diagnosis of chronic orchialgia involves a thorough clinical evaluation to rule out potential causes through physical examinations, ultrasonography, and, when clinically necessary, advanced imaging techniques. Due to the complex etiologies involved, the management of chronic orchialgia is often challenging. Conservative treatment is considered the first-line approach and includes medical therapy such as nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, and antidepressants.6 Antibiotics may be medically inidcated if an infection is suspected.

Neuromodulation techniques have also been explored for their effectiveness in managing chronic orchialgia. These include pelvic floor physical therapy and acupuncture.12 These techniques attempt to reduce pain by altering nerve activity through electrical stimulation or physical manipulation.

When conservative approaches fail, various surgical options are considered. These include:

  1. Targeted Nerve Blocks Targeted nerve blocks involve the injection of anesthetic agents near the nerves responsible for transmitting pain signals from the testis. This approach can provide temporary relief and is often used as a diagnostic tool to confirm the source of pain.7

  2. Microscopic Denervation of the Spermatic Cord (MDSC) Microscopic denervation involves the surgical interruption of nerve fibers within the spermatic cord to eliminate pain transmission. This technique has shown varying degrees of success and is 1 of the more commonly performed surgical interventions for severe cases.10

  3. Ultrasound-Guided Targeted Peri-Spermatic Cord and/or Ilioinguinal Cryoablation (UTC) Cryoablation involves the targeted freezing of nerve fibers around the spermatic cord using ultrasound guidance. This technique aims to permanently destroy the nerves responsible for pain while minimizing damage to surrounding tissues.7

  4. Botox Ablation (SCROTOX) Botulinum toxin (Botox) injections can relax muscles and reduce nerve activity, providing pain relief. SCROTOX involves the injection of Botox into the scrotum and has been explored as a treatment option for chronic orchialgia.7

  5. Peripheral Nerve Stimulation Peripheral nerve stimulation involves the implantation of electrodes near the nerves that transmit pain signals to modulate nerve activity and reduce pain perception. This minimally invasive procedure has shown promise in treating various chronic pain conditions.7

  6. Radical Orchiectomy Radical orchiectomy, the surgical removal of the affected testicle, is considered a last resort for patients with refractory chronic orchialgia. This procedure can eliminate pain but is associated with significant psychological and physiological impacts, including the potential for phantom orchialgia.3

Though the urology literature does not mention spinal manipulation and manual therapy in standard conservative care for chronic orchialgia, a growing number of publications have shown it to be safe and effective for this condition.13–17 This case demonstrates a successful treatment of chronic phantom orchialgia. A trial of chiropractic care in cases of chronic orchialgia would potentially reduce orchiectomy in idiopathic cases and could provide relief in post-orchiectomy cases.

A study has shown that low back pain with concomitant testicular pain is a presentation seen in chiropractic practice and Doctor of Chiropractic are likely to evaluate the spine and inguinal region but not the scrotal/testicular region or abdomen.18 This case highlights the need to evaluate these components or comanage as testicular pain that responds to manipulation and manual therapy could potentially have a component of testicular cancer.

Limitations

The results from this case report may not be generalized to all patients. There are many uncontrolled variables in case studies and the treatment of a single patient does not ensure equivalent results. Additionally, temporal associations do not translate to statements of efficacy.

Conclusion

This case describes the care of a veteran with low back pain and chronic phantom orchialgia using spinal manipulation and manual therapy. More research is needed on the effects of spinal manipulation and manual therapy on chronic orchialgia and chronic phantom orchialgia. Chronic orchialgia is a multifaceted condition with various underlying causes and treatment options. Conservative management remains the cornerstone of initial treatment, but surgical interventions are available for refractory cases. Phantom orchialgia adds to the complexity of managing scrotal pain, presenting unique challenges post-orchiectomy. Emerging evidence supports the role of chiropractic care and neuromodulation techniques as viable alternatives, potentially broadening the spectrum of treatment options for this debilitating condition. Continued research and clinical trials are essential to establish standardized protocols and improve patient outcomes.

Acknowledgements

Supported by the Department of Veteran Affairs. The contents do not represent the views of the Department of Veterans Affairs or the United States Government. VAGPT was used in formatting portions of this manuscript for readability.

Written consent for this publication was obtained from the patient.

Competing Interests

The authors declare that they have no competing interests.