New Orchialgia Symptom Index Could Aid Assessment, Treatment

Researchers at Cleveland Clinic and Florida’s PUR (Personalized Urology & Robotics) Clinic have developed the first index of clinically relevant symptoms for men diagnosed with chronic orchialgia. If validated, this resource would help physicians evaluate patients and judge the effectiveness of treatments in clinical and research settings.

“The index is to monitor symptom severity and response to therapy,” says Cleveland Clinic urologist Daniel Shoskes, MD, MSc, FRCS(C), a coauthor of the research presented at the American Urological Association’s 2016 annual meeting. “We are working to develop some novel interventions for orchialgia, but it is a very difficult to study without a validated way to measure symptoms. Orchialgia is one of the few conditions in urology that lacks a standardized, verified instrument to assess symptoms and their impact.”

Chronic orchialgia is a common but poorly studied and understood condition. It is defined as constant or intermittent testicular pain lasting at least three months. Its etiology is diverse and may often be unknown.

The researchers from Cleveland Clinic’s Glickman Urological & Kidney Institute and the PUR Clinic sought to devise a candidate symptom index for chronic orchialgia. Based on clinical interviews with patients and medical providers, they developed a 70-item survey that focused on seven topical areas:

• Pain intensity
• Pain location
• Urinary symptoms
• Sexual dysfunction
• Medical history
• Surgical history
• Quality of life

One hundred thirteen patients with bothersome scrotal pain lasting for at least three months and lacking etiological pathology completed the candidate survey.

What the survey found

Median symptom duration was one year. Average pain level on a scale of 1 to 10 was 4.2. Patients reported feeling pain not only in their testicles, but in the spermatic cord (66 percent), groin (66 percent), penis (24 percent), suprapubic region (39 percent), flank (31 percent), thigh (32 percent), abdomen (36 percent) and perineum (35 percent). The pain reached high bothersome levels only in testicular and spermatic cord locations.

More than half of respondents experienced erectile dysfunction (55 percent) and decreased libido (56 percent), while 39 percent reported painful ejaculation. Survey participants ranked each of those sexual symptoms as extremely bothersome.

“To have such a high incidence of sexual bother in orchialgia patients was surprising, especially in younger men,” Dr. Shoskes says. “That is something we see in other urologic pain conditions such as prostatitis and chronic pelvic pain syndrome.”

Pain affects work and lifestyle

Survey respondents’ medical histories revealed that 30 percent were diagnosed with epididymitis, 27 percent had undergone vasectomies, 17 percent suffered testicular trauma, 7 percent experienced spermatic cord torsion, and 4 percent had undescended testicles.

Survey participants said that their testicular pain most often impacted work and their ability to enjoy everyday activities.

Based on the survey responses, the researchers concluded that:

• Men with chronic orchialgia have a high incidence of associated symptoms
• The orchialgia symptoms that patients consider the most bothersome, and that have the greatest impact on quality of life, include burning pain, pain at night, pain that radiates to the groin and spermatic cord, erectile dysfunction and low libido
• A cluster of reported symptoms — urinary problems, penile and perineal pain, thigh pain, pain with ejaculation and genital numbness — suggests a subset of patients with pelvic floor spasm who are not suitable for local testicular therapy

Guided by the survey findings, the researchers created a candidate 12-question chronic orchialgia symptom questionnaire with domains for pain, sexual difficulty and quality of life impact.

“The next step is a multicenter prospective study,” Dr. Shoskes says. If validated, the symptom index could be useful for orchialgia research and in treatment guidelines.

“There has been a relative lack of academic interest and focus on orchialgia, even though it is very common,” Dr. Shoskes says. “The condition deserves to be taken seriously and looked at scientifically. A validated symptom score is the first step to make that happen.”