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Abstract

Background:

Chronic scrotal content pain, sometimes referred to as chronic orchialgia, is a common urological condition that gives rise to persistent and often severe painful stimuli to the scrotum and surrounding structures. Despite its relative commonality, accounting for over 2% of urological visits, chronic scrotal content pain is complex to manage and patients may be required to access multiple providers and undergo invasive procedures, including microsurgical spermatic cord denervation (MSCD) surgery.

Objective:

The objective of this study was to understand the experiences and perspectives of persons with chronic scrotal content pain and accessing MSCD surgery.

Design:

An exploratory qualitative design, guided by interpretive description and integrated knowledge translation, was adopted.

Methods:

We conducted in-depth qualitative interviews with six patients with chronic scrotal content pain who underwent MSCD surgery in a surgical center in Western Canada. Data were analyzed thematically.

Results:

Analysis of the study data resulted in three core themes: living with chronic scrotal content pain, quality of life, and MSCD procedure and outcomes. We highlight the debilitating nature of pain and the broad impacts upon health, quality of life, and social functioning. Participants described how MSCD surgery offered an effective solution for persistent and debilitating pain. For the participants, MSCD surgery offered hope and the chance to regain their normality.

Conclusion:

For those with chronic scrotal content pain, access to a pain specialist, along with the adoption of a biopsychosocial approach to pain and early access to MSCD surgery, may improve patient experiences and outcomes. Considering the high prevalence of urological pain, greater interdisciplinary care is needed in order to support more effective and timely management.

Keywords

Chronic pain chronic scrotal content pain lived experience microsurgical spermatic cord denervation qualitative

Introduction

Chronic pain is a common and problematic health concern linked with poor health outcomes and quality of life.¹ As a debilitating and complex healthcare issue, persons with chronic pain commonly report a range of biopsychosocial impacts, including poor health and disability, inability to maintain desired activities of daily living, impaired social relationships, financial hardship, and losses in productivity.^2,3 Globally, chronic pain is a critical public health issue and is a major reason why people seek to access healthcare. In the United States alone, it is estimated that 11–40% of all adults report some chronic pain,⁴ with a smaller proportion reporting high impact pain resulting in significant disruptions in lifestyle. This is associated with $560 billion in costs, including expenditures resulting from healthcare utilization and indirect costs resulting from the social impacts of disability and productivity losses.⁵

Chronic scrotal content pain, sometimes referred to as chronic orchialgia, is a relatively common urological condition that gives rise to persistent, and often severe, painful stimuli to the scrotum and surrounding structures, including the spermatic cord.^6,7 Chronic scrotal content pain can occur at any age. As a condition, its etiology and pathophysiology remain poorly understood; however, pain is thought to occur in response to neural changes within the affected structures, along with Wallerian degeneration which may further impact pain response.^8,9 While idiopathic chronic scrotal content pain is commonplace, other known causes include torsion, trauma, tumors, and previous vasectomy or inguinal hernia repair.^10–12

Despite its relative commonality, accounting for over 2% of urological visits,¹³ chronic scrotal content pain is complex to manage and patients may be required to access multiple health providers.¹⁴ Patients with this condition typically report debilitating pain and disability that gives rise to poor health outcomes, lower quality of life, and reduced social functioning.^15–17 Recent clinical guidelines recommend a comprehensive approach to diagnosing and managing chronic scrotal content pain that extends beyond the physical to include psychosocial aspects of pain management and support.¹⁸ This includes a comprehensive diagnostic assessment upon initial presentation to identify underlying causes, as well as delineating potential aggravating or alleviating factors.⁹ The recent development and validation of the Chronic Orchialgia Symptom Index (COSI) offers an evidence-based tool through which to comprehensively assess symptoms and disease burden. Of note, the holistic focus of this tool, including items related to pain, sexual function, and quality of life, provides a vehicle to support patient-centered and responsive pathways of care.^19,20 Medical management may further include correcting any underlying conditions, such as torsion or infection, as well as providing medication or other interventions to manage pain, including nerve blocks and physical therapy.^9,21,22 In the event that pain is persistent and not responsive to traditional management techniques, the patient may be assessed for suitability for surgical intervention.

Microsurgical spermatic cord denervation (MSCD) surgery has emerged as an effective treatment for patients with chronic scrotal content pain.^7,23 Undertaken through a small incision within the testicular unit, the procedure involves the transection of the nerve fibers within the spermatic cord and associated structures. Through this, the neural and pain pathways are disrupted, whereas care is taken to preserve the arterial and lymphatic anatomy. To date, MSCD has been demonstrated to provide effective and durable relief in 71–96% of cases.^7,14,24–27 For example, Calixte and colleagues²⁴ conducted a single center case review of 860 patients who underwent robotic–assisted MSCD for chronic orchialgia or groin pain. Their analysis demonstrated that 83% of patients experienced significant pain reduction, with almost half of these experiencing complete resolution of pain. Similarly, Cassidy²³ undertook an analysis of nine consecutive patients who underwent MSCD surgery. A significant reduction in pain was achieved, with over three-quarters of the patients achieving complete relief and one in five experiencing a partial response with minimal remaining pain or symptoms.²³ Likewise, Marconi et al.²⁵ found that of patients that underwent the procedure, 80% were pain free at 6-month follow-up, 12% experienced a partial response, and 8% reported no change.²⁵ Overall, MSCD offers a promising opportunity for lasting relief of chronic scrotal content pain.²²

Despite the growing evidence base on the surgical management of chronic scrotal content pain, there is a lack of research that has explored patient experiences of accessing care and of undergoing this procedure. Furthermore, men’s experiences of pain are in general poorly understood and under-researched,²⁸ resulting in gaps in knowledge related to pain interventions and potentially ineffective care.

Methods

To understand the experiences and perspectives of persons with chronic testicular pain and accessing MSCD, we undertook a qualitative study guided by interpretive description²⁹ and an integrated knowledge translation (IKT) approach.³⁰ The interpretive description approach to studying human experiences seeks to create interpretive accounts that can generate applied knowledge.³¹ Furthermore, IKT ensured our research was grounded within practice and our interdisciplinary team, including experts in urology and pain, worked collectively to design and execute this study.

Sample

A purposive sample of seven participants were recruited to participate in the study, with six participants completing the interview (one participant was lost to follow-up). To be eligible for inclusion, participants needed to be over 18 years of age, have lived experience of chronic scrotal pain and MSCD, and able to provide informed consent. Participants were recruited through a surgical office offering specialist urological surgery in western Canada. All eligible participants received a letter or invitation and comprehensive information sheet (N = 22). Reminder letters were distributed 1 and 3 months following the initial invitation. Recruitment occurred between September 2017 and June 2019.

Data collection and analysis

Data collection and analysis occurred simultaneously. To generate in-depth and rich accounts, semi-structured interviews were conducted by an experienced female qualitative researcher (DB). Telephone interviews lasting up to 90 min were digitally recorded and transcribed verbatim, and detailed notes were taken during the interviews. A preliminary interview schedule was used to guide the interviews, although the interview process was exploratory and participants were encouraged to describe their experiences and events that were meaningful to them. During the final interviews, additional questions were included to further explicate the theoretical data emerging from the analysis. Examples included asking participants to describe their processes of seeking help over the course of their pain journey and how their pain impacted their relationships and activities of daily living.

Transcripts were cleaned, anonymized, and read closely to allow for immersion and familiarity. Initial codes were generated independently by two researchers (DB and CA), then compared and revised to refine the emerging analysis. While all participants were offered the opportunity to review their transcripts, no participants requested this. Over time, themes and interconnections within the data were generated, refined, and documented. We worked with our principal knowledge user (DC) to inform our analysis and support the interpretation of the study findings. Upon completion of six in-depth interviews, saturation was achieved, meaning that no new major themes were present and the analysis was comprehensive.³²

Rigor

Prolonged immersion in the data, peer checking of analysis, and the production of rich descriptions were undertaken to foster credibility and trustworthiness. Ongoing reflexive practice was undertaken to critically examine preconceived ideas and to challenge dominant clinical discourses.

Findings

Seven men were recruited from a specialist urology clinic in a Western Canadian province and six participants (aged 18–55 years) completed an in-depth interview. Analysis resulted in three core themes: living with chronic scrotal content pain, quality of life, and MSCD procedure and outcomes.

Living with chronic scrotal content pain

Chronic scrotal content pain was experienced for varying durations of time, ranging from 2 to 7 years. Pain was typically described as severe, including qualities of tenderness, sharpness, deepness, and aching; it varied in terms of its presentation, duration, and impacts. In this population, participants reported that pain onset often occurred suddenly, resulting from previous surgical complications, infection, and trauma to the testicles and associated structures, whereas one reported pain from idiopathic causes. For example, one participant recalled his experience following vasectomy, reporting:

I went for a vasectomy and as soon as the freezing wore off I was in . . . agony . . . I couldn’t walk upstairs, any time like if I was driving around, any time I hit a speed bump I’d throw up. It was bad. (P006)

When asked to report their typical pain score before surgery, participants reported pain ranging from 6 to 10/10 on a visual analog scale.³³ For many, some level of pain was always present, but severe pain was intermittent and exacerbated by any activity that caused the testicles to move. For example, one patient describes it as ‘a sharp sudden pain’ (P001), for others, pain was enduring and distressing.

Despite the individual nature of the pain experience, all participants described major challenges managing their pain, with little access to needed supports. All participants reported the need to restrict and reduce activities, with many highlighting that they felt forced to rest in order to reduce pain to a more manageable level. In addition, participants relied upon medication to manage their pain, including opioids and other strong analgesics. While participants expressed reluctance to use strong analgesics, most felt they had little option. For example, when asked about pain management, one participant shared: ‘I was up to 80 mgs of Oxycontin a day’ (P006), whereas another commented that he was ‘taking over the counter medication like on an hourly kind of basis’ (P004).

In most cases, participants reported receiving care from multiple healthcare providers, including a family physician and urologist. Through this, participants recall a process of trial and error with medications, as well as trying any other therapies or tools that might offer relief, including support garments, pain interventions, and alternative therapies. One participant explained ‘I went to my family doctor, several times, for about the first year and it was three or four different medications and I just got tired cause none of the medications would end up working’ (P001), whereas another stated:

Every two weeks, they’d give me a two-week prescription and something wouldn’t work and they’d pump me full of something else. Here try this one, here try this one and nothing worked. I was always in pain. (P003)

Others tried more invasive procedures, including nerve blocks. One participant recalled being debilitated with pain and unable to hold his children due to severe pain. Upon receiving a nerve block, the participant reported complete, but temporary, relief followed by the distress as the pain returned. They shared:

I drove home from [City] to [City] which is normally 3 ½ hours, I did it in 2 hours and 10 minutes just to get home to pick up my kids from school so I could pick them up and swing them around . . . it was heavenly. I picked the kids up at school and I started crying, I was freaking parents out in the school and I was like I don’t care. Like I can pick my children up for the first time in like two years . . . that was very difficult to go from no pain or discomfort [back] to full out kick in the balls by a Clydesdale again, right. (P003)

In most all cases, participants reported only minor relief from medications and pain interventions and recalled the need to continually search for help. One participant explained ‘I found, like I couldn’t get answers and you couldn’t really get anybody to help. Nobody knew how to deal with pelvic pain’ (P004), whereas another described the process of help seeking as a ‘self-directed process’ (P002), continuing to say that:

Definitely a lot of uncertainty and just I guess, I’m optimistic at first, but after repeated treatments, like I just got more pessimistic cause I wasn’t sure if the next treatment would be the one. I didn’t want to get my hopes up too much or anything like that. So, I guess it was just kind of discouraging to have treatment after treatment until I realized it just wasn’t working. (P005)

Quality of life

Participants described at length the enduring effects of severe chronic scrotal content pain and its lasting impacts on quality of life, including significant physical, financial, and social limitations. During the interviews, all participants reported significant physical limitations due to their pain, leaving many unable to engage in their usual work and social activities. Productivity at work was often affected, most dramatically in those with physically demanding jobs. Example, one participant explained how they frequently missed work due to their pain, commenting: ‘I missed work . . . in the end it did kind of end up looking bad’ (P001), while another commented: ‘I just about lost everything. Cause I couldn’t work’. (P006). For four participants, their condition gave rise to significant shifts in roles and pay. During the interview, one participant became emotional while describing the financial impacts of his illness, explaining how his pay was reduced by over 60% as he was moved into a desk position while undergoing treatment, only to find himself unable to move back into his previous role once recovered. He explained ‘My whole being suffered because of what I was going through, and I was getting to the end of my rope. I was angry’ (P003). Others felt the need to do what they could to get by and remain engaged in work. As the sole provider for the family, one participant described their need to push through the pain, commenting: ‘I forced myself to work through it. It was extremely excruciating and painful, but it had to be done so I did it’ (P003). Another shared how work was a help to them:

Like, with the meds I’m able to work and it was kind of, you tossed around the idea do you sit at home and be a vegetable or do you take the pills knowing they’re not good for you and try to work? And I chose to try to work, and I feel happier about it. (P004)

Social limitations were widely experienced, with participants reporting an inability to engage in their usual activities due to their pain and related symptoms. Many participants withdrew from social situations, such as visiting gyms or attending social events, becoming increasingly isolated over time. For example, one participant commented that: ‘I wouldn’t want to go out and do anything’ (P001), whereas another explained: ‘I couldn’t be physically active, the way I wanted to be. I couldn’t do sports or anything like that so that was just a rough time for me’ (P005). Finally, another participant explained how these experiences led to feelings of isolation.

Socially you kind of withdrew a bit cause you couldn’t go out and have as much fun because you were in pain, and you know you’d go out and then you’d be in pain . . . it would just kind of diminish [you]. (P004)

Social impacts often led to insecurities and negative feelings of self-worth. One participant recalled that he needed support with ‘a lot of day-to-day functions, it was really, really difficult for me to carry out and I needed help’ (P003), whereas another explained that the pain ‘kind of shuts your whole life down’ (P006). The emotional toll looked different depending on the participants’ age, existing supports, values, and openness to others. Younger patients were often less open about their condition with others, leading to feelings of loneliness. For example, one participant explained:

it was a very delicate time and again isolating, cause I felt like this was a problem that set me apart from people because I couldn’t talk about it so I just felt really alone during that time. Like it made me feel different from my peers just because I had this problem that I felt like was uncommon for people my age. (P005)

In contrast, older participants often explained being more open with others, but typically suffered more emotional distress as they battled to maintain their responsibilities at home and work.

For five participants, the impacts of this condition upon their personal relationships and sex life were profound. For one participant, their experience of pain and difficulties engaging in sex was perceived to have contributed to a breakdown in their relationship, stating that ‘my marriage broke down, I ended up, well I’m still fighting depression. Ya, it just, ya. The whole, ya, just totally ruins your life’ (P006). Of the five participants, all reflected on how painful sex had been during their time with chronic scrotal content pain, and that sex often left them with worsening pain for a period afterward. One participant explained ‘if you had sex, it would hurt so bad for a week, you had to take way, way more pills to be able to have sex’ (P004). Participants described how these difficulties contributed to tensions in their relationships and that they worked to find solutions for themselves and their partners. For example, one participant explained how they increased their pain medication to allow them to have sex, commenting:

You need that in a marriage and a relationship to keep you bonded. It’s part of your bonding, right. And ya, I mean my sex life suffered greatly and it was difficult but when it was time for it, I just quadruple up on my [oxycontin] pills and if it put me in a coma well, at least I went out happy. (P003)

These ongoing physical, social, and financial challenges related to their chronic pain led to frustration, as well as uncertainty and sometimes despair, for all participants. One participant commented that ‘the pain was always there so it’s kind of hard to push it to be the back of my mind. So, it was a very distressing time for me actually’ (P005). When asked about sources of support, most participants felt able to reach out to their partners, friends, and co-workers; however, participants reported the fragile balance of seeking support and not being a burden on others. For example, one participant explained: ‘There was some support, you know. You had family and nobody could really do anything for you but part of thing with that is you also, you don’t want to drag everybody else down as well’ (P003). Participants explained how camaraderie and humor between friends and co-workers was used when talking about their health issues and was helpful. One participant explained: ‘it became a joking matter so to speak, kind of weird I know, but it got us all through it, right’ (P003) while another commented:

I’m very open with myself, I don’t really care about what other people think in the worst way, and I do have pretty good friends. Like I kept a lot of my good friends that understood and they’re like ‘ya, man, just take your time, do what you got to do’, kind of thing. (P001)

In contrast, one participant described feeling engulfed and isolated by their pain, with limited avenues of support. For this participant, they recognized how delicate and sensitive the issues are and that having the opportunity to connect with others facing similar issues would have been helpful. They explained:

I really felt like I couldn’t talk to people about it, just because it was kind of, I just felt like it would be embarrassing to talk about it. Just like it has to do with a part of your body that a lot people are really sensitive about and not something you can easily discuss with anyone. I didn’t really have support. The only people were really my parents and even then they were kind of uptight about it, so I didn’t really have anyone to talk to about my problem. It was pretty isolating. (P005)

The process of accessing supports for chronic scrotal content pain was haphazard and participants described at length the difficulties they faced. For many participants, the challenge of receiving care from multiple providers and the need to seek out potential sources of support was difficult. One participant commented on the need for better guidelines and information for patients with chronic scrotal content pain and how this may assist them when navigating the health system. They explained:

Like just having a wider picture of the things that could be implicated in these conditions would be helpful for patients so they would have a better knowledge base to work with. A better place to start [when] looking for treatment. (P005)

For others, access to emotional and mental health supports were seen as valuable. One participant commented that: ‘if I had someone to talk to about my problem would definitely would have alleviated a lot of that emotional component’ (P005). Another participant explained that they would have liked to connect with peers, stating:

I didn’t know anyone going through anything similar, right. But had I have known, like if the doctor said hey this is what you could be suffering from, here’s a website of testimonials or here’s a website where you can link up with people that have similar symptoms, ya, I could see that might’ve been helpful cause then you’re talking to someone that is actually familiar with what you’re going through. (P003)

All participants shared that their pain experience had lasting impacts, with two participants expressing that they had regularly contemplated self-harm and suicide. One participant shared ‘it was bad enough I was going to kill myself to stop it’ (P006), whereas another felt that they were living with trauma as a result of their pain experience:

Ya, like I guess there’s some kind of negative thought pattern that’ll carry over, like cause when this was happening, I was like very limited and I just felt very hopeless and I got into this negative cycle of looking at myself and looking at the world that I’m still kind of working through and like that. So, there’s long-lasting emotional scars that are still healing. (P005)

MSCD procedure and outcomes

For many participants, the decision to undergo the MSCD surgery was easy, due to the lack of available options and the ongoing challenges of living with severe pain. One participant commented:

[surgeon] says it might help, it might not, and he kind of said it was a 50/50 shot . . . you don’t hear that worse part because you’re in pain and you’re just looking for anything . . .if somebody could tell me if I cut everything out it would help, I would do it. (P004)

For others, the decision to undergo surgery felt like it was their last chance, since other attempts to manage the pain had failed. One participant explained that the surgery felt like ‘a glimmer of hope that there might be a cure for this disease, for the pain’ (P005), whereas another shared:

I just had faith and I just hoped for the best. It was worth the shot, instead of being on medications for the rest of my life or dealing with that pain, was kind of my last choice. Cause I didn’t really have anything else. (P001)

Although being faced with limited options, some participants shared that they felt apprehensive about the surgery, fearing that it would not be successful or may result in further issues. A common concern outlined by younger participants was the sparing of their fertility (a common risk associated with this surgery). One participant explained that while being relieved to be offered surgery, the potential risk to his fertility was ‘scary’: ‘I was 23 at the time, I’m 24 now . . . I don’t have any kids. I would like to have kids. So, it was scary in that sense’ (P001).

When reflecting upon their experience of undergoing MSCD surgery, all participants reported being happy with the surgical experience itself. During the perioperative period, one participant recalled: ‘they understood that I was coming in for a very serious operation and they, you know, they all treated me with care and they were happy and bubbly’ (P004), whereas another felt grateful to the surgical team, noting ‘how professional and how educated and calming [the surgeon] was with the whole procedure, he understood where I was coming from’ (P001).

The most common symptoms following surgery were pain around the incision, swelling, and bruising:

I was just like yellow around my legs and my belly button and then the actual swelling itself was pretty much like having a five-pin bowling ball between my legs for the first four or five days I’d say and then the swelling kind of started to go down. (P001)

Symptoms decreased as time passed and participants were quickly able to regain some of their activities. One participant commented: ‘I was up and walking around within a week. Pretty much out of pain within two weeks’ (P006). In contrast, one participant reported a more delayed recovery, experiencing some complications following surgery and requiring further surgery. Regardless of their surgical journey, all participants experienced lasting pain relief, with most reporting no or minimal pain following MSCD surgery. By addressing their pain, participants felt able to live a healthier lifestyle and regain a sense of normality, commenting that ‘my life is normal again’ (P003) and that ‘Somebody just handed you your life back’ (P006). When reflecting on their life since surgery, one participant explained that they could see a future with hope, stating that ‘I feel like there’s a lot of positives ahead of me, I’ve got a brighter future now’. (P005).

Discussion

This study provided an in-depth exploration of the experience of chronic scrotal content pain and undergoing MSCD surgery, demonstrating the broad physical, social, and emotional impacts faced by persons with this condition. Overall, MSCD surgery provided a life changing opportunity to address chronic scrotal content pain.

Persons with this condition were often faced with the need to actively seek out help, while living through a process of trial and error with medication and treatments. Chronic unmet pain needs also led many to engage in risky medication practices, including taking large doses of medications to manage and mitigate pain. Concerns related to the use of strong analgesics, including opiates, has been widely documented.³⁴ Nonetheless, growing calls for greater balance when treating chronic pain have been made, with many highlighting the increasing challenges of unmet pain needs.^35,36 For example, Vranken et al.³⁶ highlighted the growing crisis of uncontrolled and undertreated chronic pain due to a growing fear and hesitancy to prescribe opioids. A reluctance to prescribe medically needed opiates, along with a lack of confidence in pain management, has been previously documented and may contribute to poor pain management in this population.³⁷

Considering the high prevalence of urological pain, greater interdisciplinary care, including the engagement of pain specialists, clinical psychologists, and physical therapists, may provide more effective and timely management.^38–42 However, many patients with chronic pain report significant barriers to accessing support, including the inadequate preparation of healthcare providers, different expectations between patients and providers, and financial or geographical challenges.⁵

Despite their attempts to seek care, many study participants reported poor pain control, resulting in significant challenges in maintaining their normal social roles, including workplace functioning and social engagement. This had lasting financial consequences and directly impacted their interpersonal relationships and sexual functioning. The importance of social networks and support has been identified in other pain literature, with studies highlighting the adverse impacts of social isolation on coping and the impacts of pain.⁴³ In the longitudinal study by Karayannis and colleagues, the impact of pain was reduced in those with greater social inclusion and engagement and the authors noted the potential of therapeutic interventions that optimize social connectedness and pain outcomes.

In addition to social connectedness, this study also captured the pain experiences as being highly grounded within socially constructed gender ideals. For most participants, coping and productivity were highly valued. When pain disrupted their physical functioning, participants reported internal struggles and feelings of isolation and failure.⁴⁴ The nature and severity of participants’ pain resulted in many being unable to work for extended periods or having to change their type of work. For most, this had major financial implications and led to many feeling depressed, isolated, and unvalued. These feelings were heightened in the participants that held more traditional roles within the family unit, such as being the sole financial provider. Although these factors have been reported in those suffering with chronic pain more generally, participants in this study recognized the impacts of uncontrolled pain and inability to fulfill their gendered roles as being dehumanizing.^2,45

Sex and gender-based experiences of pain are well established in the literature, with a significant body of evidence being dedicated to experiences of genital pain among women.^46–48 However, discourses exploring men’s pain are largely missing and represent a significant gap in the literature.^28,48 Of the limited literature available, men are less likely to seek medical care or have access to care that has been identified as ‘male-friendly’.⁴⁴ Furthermore, the dearth of research exploring men’s experiences of chronic urological pain may further contribute to gaps in care and may in turn hinder effective management.²⁸ In this study, participants talked at length about the impacts of their pain, noting that pain experiences threatened their sense of value and worth, with the majority expressing feelings of distress as they have become unable to provide for their loved ones and maintain a sense of normality.⁴⁹ Furthermore, men experience challenges in accessing supports from others, often relying on camaraderie and humor to navigate these challenging times.⁵⁰ Likewise, some participants explained how they often engaged in risky medication behaviors (e.g. taking high levels of opiates) in the attempt to overcome the limitations, including when engaging in sexual activity, and had contemplated suicide as attempts to gain relief from pain continued to fail. The link between chronic pain, substance use disorders, and suicide is well established,^51–53 and there is a need for effective interventions to address pain and the psychosocial elements of that experience,⁵¹ including a need to explore sexual health and functioning.⁵⁴

Despite the convoluted journey, participants were enthusiastic about the potential of MSCD surgery as a permanent strategy to manage pain. In this study, the decision to undergo surgery was driven by the participants’ experience of ongoing failures in pain management, with many explaining that they actively searched for interventions to manage their pain and had little choice but to try surgery. For most participants, MSCD surgery provided lasting relief from pain and offered an opportunity to regain normality and to engage fully in their lives. This is consistent with other MSCD studies, which highlight significant reductions in pain.²⁷ Despite a growing evidence-base to support its use, access to MSCD remains limited and patients typically undergo extensive rounds of assessment and treatment before accessing this. Opportunities exists to develop a patient care pathway, highlighting evidence-informed approaches to chronic scrotal content pain and to provide a framework for coordinated interdisciplinary care.

All participants reported lasting emotional impacts of these experiences, even after what was perceived as a successful surgery to manage pain. The broader psychosocial impacts of urological pain have not been well explored, and study findings begin to highlight the complexity of pain for this population. Further research is needed to better understand the management of pain in this population, including factors contributing to its undermanagement, along with research to identify effective models of care.

The interpretive description²⁹ and IKT³⁰ approaches in our study reinforced the need to collect comprehensive, contextualized, and responsive data to inform the development of relevant and impactful health services. Through this work, we responded to the existing knowledge gap by providing a rich and detailed analysis of pain in men with chronic scrotal content pain and described their experiences seeking surgical help and healing. We have highlighted gaps in care and raise awareness of opportunities to foster more holistic and coordinated patient-centered care.

Recommendations

Adopting a patient-centered and interdisciplinary approach to the management of chronic scrotal content pain is a primary way to optimize patient experiences and outcomes. This includes facilitating early access to comprehensive pain care provided by a range of interdisciplinary professionals, optimizing the delivery of guideline-based care for chronic scrotal pain, promoting shared care among providers to allow for coordinated care, and finally, to monitor and evaluate the effectiveness of care with the patient.⁵ As evidenced in this study, many men experienced intense pain that resulted in long-lasting distress and trauma. Despite the severity of their symptoms, participants expressed challenges in accessing care and felt that there were limited options available. Adopting a coordinated approach to care, including integrated psychosocial supports and timely access to MSCD, would be valuable and may enable more effective and rapid management. For example, the inclusion of a pain specialist and clinical psychologist or counselor within the care team may facilitate effective pain control, promote healthy coping mechanisms, and would offer immediate assistance for those in distress or experiencing trauma. Likewise, the integration of holistic screening tools may support healthcare providers to identify unmet needs, including a standardized assessment for pain and quality of life.^28,44 To achieve this, targeted education for diverse healthcare providers, including primary care providers and urologists, are necessary to raise awareness of the needs of those with chronic scrotal content pain.

Limitations

Our research design has allowed us to explore the journeys and perspectives of persons with chronic scrotal content pain and their experience of undergoing MSCD surgery, contributing patient-oriented insights and recommendations. Despite these strengths, there are two main limitations to note. First, despite attempts to engage a larger population of patients in this research, our sample size was small (approximately 27.3% of the accessible population). As genital pain is highly sensitive and personal, it is possible that this was a barrier for some participants to take part in the study. Despite this, we were successful in generating comprehensive accounts of experience and achieved data saturation with respect to the main study concepts. However, we recognize that engaging further participants may yield additional insights. Second, study participants were recruited from one surgical clinic in Western Canada. Engaging other clinical sites may also yield new and potentially different insights. At time of this study, there were only two clinics in Canada that offered this procedure; therefore, further research may seek to include international centers to gain greater breadth and diversity.

Conclusion

Chronic scrotal content pain, a relatively common urological condition, gives rise to persistent and often severe painful stimuli to the scrotum and surrounding structures, including the spermatic cord.^6,7 Through in-depth interviews with six patients with chronic scrotal content pain, we described the debilitating nature of pain and its broad impacts upon health, quality of life, and social functioning.^15–17 MSCD surgery offers an evidence-based and effective solution for patients with persistent and debilitating pain. For participants, MSCD surgery offered hope and the chance to regain their normality.

Footnotes

Acknowledgements

We would like to acknowledge and thank our participants for sharing their experiences and insights.

Declarations

ORCID iDs

Davina Banner

Shannon Freeman

References

Chronic Pain Association of Canada. CAPC Pain Report 2019 – Shamed, abandoned, and suicidal. How bad policy hurts Canadians in pain. Edmonton, Canada: Chronic Pain Association of Canada, 2019.

Driscoll

Knobf

Higgins

, et al. Patient experiences navigating chronic pain management in an integrated health care system: a qualitative investigation of women and men. Pain Med 2018; 19: S19–S29.

Parekattil

. Targeted microsurgical denervation of the spermatic cord for chronic orchialgia: the current standard of care. Curr Urol Rep 2020; 21: 47–54.

Dahlhamer

Lucas

Zelaya

, et al. Prevalence of chronic pain and high-impact chronic pain among adults – United States, 2016. MMWR Morb Mortal Wkly Rep 2018; 67: 1001–1006.

Institute of Medicine (US). Committee on advancing pain research, care, and education. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington, D.C.: National Academies Press, 2011.

Ciftci

Savas

Yeni

, et al. Chronic orchialgia and associated diseases. Curr Urol 2010; 4: 67–70.

Levine

Hoeh

. Evaluation and management of chronic scrotal content pain. Curr Urol Rep 2015; 16: 1–8.

Parekattil

Gudeloglu

Brahmbhatt

, et al. Trifecta nerve complex: potential anatomical basis for microsurgical denervation of the spermatic cord for chronic orchialgia. J Urol 2013; 190: 265–270.

Tatem

Kovac

. Chronic scrotal pain and microsurgical spermatic cord denervation: tricks of the trade. Transl Androl Urol 2017; 6: S30–S36.

10.

Christiansen

Sandlow

. Testicular pain following vasectomy: a review of postvasectomy pain syndrome. J Androl 2003; 24: 293–298.

11.

Inaba

Okinaga

Fukushima

, et al. Chronic pain and discomfort after inguinal hernia repair. Surg Today 2012; 42: 825–829.

12.

McMahon

Buckley

Taylor

, et al. Chronic testicular pain following vasectomy. Br J Urol 1992; 69: 188–191.

13.

Strebel

Leippold

Luginbuehl

, et al. Chronic scrotal pain syndrome: management among urologists in Switzerland. Eur Urol 2005; 47: 812–816.

14.

Heidenreich

Olbert

Engelmann

. Management of chronic testalgia by microsurgical testicular denervation. Eur Urol 2002; 41: 392–397.

15.

Aljumaily

Al-Khazraji

, et al. Quality of life in men with chronic scrotal pain. Can J Pain 2017; 1: 106–111.

16.

Lian

Shah

Mueller

, et al. Psychological perspectives in the patient with chronic orchialgia. Transl Androl Urol 2017; 6: S14–S19.

17.

Turk

Okifuji

. Perception of traumatic onset, compensation status, and physical findings: impact on pain severity, emotional distress, and disability in chronic pain patients. J Behav Med 1996; 19: 435–453.

18.

Jarvi

Nickel

, et al. Canadian urological association best practice report on chronic scrotal pain. Can Urol Assoc J 2018; 12: 161–172.

19.

Polackwich

Arora

, et al. Development of a clinically relevant symptom index to assess patients with chronic orchialgia/chronic scrotal content pain. Transl Androl Urol 2018; 7: S163–S168.

20.

Shoskes

Calixte

Tadros

, et al. Validation of the chronic orchialgia symptom index for men with chronic orchialgia/chronic scrotal contents pain. Urology 2018; 119: 39–43.

21.

Bajic

Lundy

, et al. Chronic scrotal content pain: a review of the literature and management schemes. Curr Urol Rep 2021; 22: 1–9.

22.

Calixte

Brahmbhatt

Parekattil

. Chronic testicular and groin pain: pathway to relief. Curr Urol Rep 2017; 18: 83–88.

23.

Cassidy

. Early experience with microsurgical spermatic cord denervation for chronic orchialgia at a Canadian centre. Can Urol Assoc J 2015; 9: 72–e74.

24.

Calixte

Tojuola

Kartal

, et al. Targeted robotic assisted microsurgical denervation of the spermatic cord for the treatment of chronic orchialgia or groin pain: a single center, large series review. J Urol 2018; 199: 1015–1022.

25.

Marconi

Palma

Troncoso

, et al. Microsurgical spermatic cord denervation as a treatment for chronic scrotal content pain: a multicenter open label trial. Urol J 2015; 194: 1323–1327.

26.

Oomen

RJA

Witjens

van Wijck

AJM

, et al. Prospective double-blind preoperative pain clinic screening before microsurgical denervation of the spermatic cord in patients with testicular pain syndrome. Pain 2014; 155: 1720–1726.

27.

Strom

Levine

. Microsurgical denervation of the spermatic cord for chronic orchialgia: long-term results from a single center. Urol J 2008; 180: 949–953.

28.

Quallich

Arslanian-Engoren

. Chronic testicular pain in adult men: an integrative literature review. Am J Men's Health 2013; 7: 402–413.

29.

Thorne

. Interpretive description: qualitative research for applied practice. 2nd ed. London: Routledge, 2016.

30.

Graham

Logan

Harrison

, et al. Lost in knowledge translation: time for a map? J Contin Educ 2006; 26: 13–24.

31.

Thorne

Kirkham

O’Flynn-Magee

. The analytic challenge in interpretive description. Int J Qual Methods 2004; 3: 1–11.

32.

Fusch

Ness

. Are we there yet? Data saturation in qualitative research. Qual Rep 2015; 20, 9: 1408.

33.

Langley

Sheppeard

. The visual analogue scale: its use in pain measurement. Rheumatol Int 1985; 5: 145–148.

34.

Volkow

McLellan

. Opioid abuse in chronic Pain – Misconceptions and mitigation strategies. The New Engl J Med 2016; 374: 1253–1263.

35.

Greco

Roberto

Corli

, et al. Quality of cancer pain management: an update of a systematic review of undertreatment of patients with cancer. J Clin Oncol 2014; 32: 4149–4154.

36.

Vranken

MJM

Schutjens

MHDB

Mantel-Teeuwisse

. The double opioid crisis: a call for balance. Pharmacoepidemiol Drug Saf 2019; 28: 1–3.

37.

Keller

Ashrafioun

Neumann

, et al. Practices, perceptions, and concerns of primary care physicians about opioid dependence associated with the treatment of chronic pain. J Subst Abuse Treat 2012; 33: 103–113.

38.

Eccleston

Morley

Williams

. Psychological approaches to chronic pain management: evidence and challenges. Br J Anaesth 2013; 111: 59–63.

39.

Gatchel

McGeary

, et al. Interdisciplinary chronic pain management: past, present, and future. Am Psychol 2014; 69: 119–130.

40.

Hylands-White

Duarte

Raphael

. An overview of treatment approaches for chronic pain management. Rheumatol Int 2017; 37: 29–42.

41.

Kress

Aldington

Alon

, et al. A holistic approach to chronic pain management that involves all stakeholders: change is needed. Curr Med Res Opin 2015; 31: 1743–1754.

42.

Tripp

. Managing psychosocial correlates of urologic chronic pelvic pain syndromes: advice from a urology pain psychologist. Can Urol Assoc J 2018; 12: S175–S157.

43.

Karayannis

Baumann

Sturgeon

, et al. The impact of social isolation on pain interference: a longitudinal study. Ann Behav Med 2019; 53: 65–74.

44.

Keogh

. Men, masculinity, and pain. Pain 2015; 156: 2408–2412.

45.

Bernardes

Lima

. Being less of a man or less of a woman: perceptions of chronic pain patients’ gender identities. Eur J Pain 2010; 14: 194–199.

46.

Fillingim

King

Ribeiro-Dasilva

, et al. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain 2009; 10: 447–485.

47.

Mogil

. Sex differences in pain and pain inhibition: multiple explanations of a controversial phenomenon. Nat Rev Neurosci 2012; 13: 859–866.

48.

Ahlsen

Mengshoel

Solbrække

. Troubled bodies – troubled men: a narrative analysis of men’s stories of chronic muscle pain. Disabil Rehabil 2012; 34: 1765–1773.

49.

Charmaz

Sabo

Frederick-Gordon

. Identity dilemmas of chronically 111 men. In Strauss

Corbin

(eds), Grounded Theory in practice. Thousand Oaks, CA: Sage, 1997, pp. 35–63.

50.

Schover

. Psychological factors in men with genital pain. Cleve Clin J Med 1990; 57: 697–700.

51.

Lynch

Katz

. One size fits all” doesn’t fit when it comes to long-term opioid use for people with chronic pain. Can J Pain 2017; 1: 2–7.

52.

Moulin

Clark

Speechley

, et al. Chronic pain in Canada – prevalence, treatment, impact and the role of opioid analgesia. Pain Res Manag 2002; 7: 179–184.

53.

Racine

. Chronic pain and suicide risk: a comprehensive review. Prog Neuropsychopharmacol Biol Psychiatry 2018; 87: 269–280.

54.

Puhse

Wachsmuth

Kemper

, et al. Chronic pain has a negative impact on sexuality in testis cancer survivors. J Androl 2012; 33: 886–893.

Chronic scrotal content pain: the experiences of patients undergoing microsurgical spermatic cord denervation

Abstract

Background:

Objective:

Design:

Methods:

Results:

Conclusion:

Keywords

Introduction

Methods

Sample

Data collection and analysis

Rigor

Findings

Living with chronic scrotal content pain

Quality of life

MSCD procedure and outcomes

Discussion

Recommendations

Limitations

Conclusion

Footnotes

Acknowledgements

Declarations

ORCID iDs

References