Chronic testicular pain

[gator2886]

Chronic testicular pain
Pudendal, Genitofemoral, ilioinguinal, all failed. Lyrica, Cymbalta, Narcs, Gabapentin, tramadol, anti depressant all fail. MRI of spine is perfect. Someone tried TFESI without success. Ideas? Would SCS help? Will insurance cover? Thanks

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[deleted875186]

Ganglion of impar maybe?

 

[deleted875186]

Which nerve root did someone inject? Would have suggest sacral DRG but if no relief from TFESI ....

Assuming they had a complete urology workup and check for hernias etc?

 

[Orin]

Chronic testicular pain
Pudendal, Genitofemoral, ilioinguinal, all failed. Lyrica, Cymbalta, Narcs, Gabapentin, tramadol, anti depressant all fail. MRI of spine is perfect. Someone tried TFESI without success. Ideas? Would SCS help? Will insurance cover? Thanks

Where in the testicle, superior/lateral/anterior/posterior/deep? Bilateral or unilateral? Changes with mechanical maneuvers, functional usage, etc?

I would first ask who and how they did the nerve blocks, as if you've taken out all peripheral sources, then you would consider something centrally. I prefer to do blocks with sensory stimulation as sometimes the nerve isn't in the right area.

The testicular innervation can come from as high as T10-T11 for visceral sympathetic fibers and then down below S2. I might consider a saddle block vs a thoracic epidural with local to see where this is coming from. If it gets better with a chloroprocaine saddle block, then you could consider sacral nerve root blocks/DRG. If it gets better with the thoracic epidural, then you're looking to aim high.

 

[lobelsteve]

Just take it out.

 

[bedrock]

S2 + L1 DRG trial

 

[Ligament]

Confirm the blocks yourself if you did not do them. Lots of people still doing blind pelvic blocks. In young men I've seen lumbar facets or discs refer testicular pain, though rare. Could try lumbar MBB even with a pristine MRI. Consider athletic pubalgia; he may be percieving it as testicular pain. Tender rectus or adductors? Try bocking the rectus adductor aponeurosis.

 

[gator2886]

I did not do the TFESI's. Patient has had complete urology work up. I tried the peripheral blocks lyrica and cymbalta.

 

[Orin]

I did not do the TFESI's. Patient has had complete urology work up. I tried the peripheral blocks lyrica and cymbalta.

The S2-S4 DRGs are what most would argue go to the scrotum. As I stated, you can get sympathetic innervation from T10-L2 contributing.

There is case report of genitofemoral issues caused by weird peripheral nerve sheath tumors irritating the L1-L2 nerve root presenting as just unilateral scrotal pain.

Use of Spermatic Cord Block Systematically Identifies a Paraspinal Tumor as Source of Orchialgia

Orchialgia is a common urologic complaint with a myriad of etiologies. Workup for orchialgia requires a broad differential diagnosis and a thorough understanding of relevant anatomy. We report the case of a 43-year-old man who presented to a urologist ...

www.ncbi.nlm.nih.gov

The fibers directly run in the spermatic cord, so you could do a true spermatic cord block to see if you can quiet it down. Otherwise, I am concerned about the ability for you to help with anything.

Ultrasound-guided spermatic cord block for scrotal surgery

AbstractBackground. Performing spermatic cord block for scrotal surgery avoids the potential risks of neuraxial and general anaesthesia and provides long-l

academic.oup.com

I would really prefer to see some benefit from a block at some point before I chase stimulation as you're not sure where you'd be stimulating otherwise. This is a good case for an academic place that has time to not be productive.

 

[bedrock]

The S2-S4 DRGs are what most would argue go to the scrotum. As I stated, you can get sympathetic innervation from T10-L2 contributing.

There is case report of genitofemoral issues caused by weird peripheral nerve sheath tumors irritating the L1-L2 nerve root presenting as just unilateral scrotal pain.

Agree re innervation, which I why I recommend an L1 and S2 DRG trial. You test them both during the trial, and typically most patients just need one or the other for the perm. Some benefit from both.

 

[SSdoc33]

most common etiology of orchialgia, at least in the patients i see, is L5-S1 referred disc pain. as the pain is referred, this one of the few occasions where an interlaminar ESI seems to be a better choice IMHO. make sure you exhaust all of the more conservative options before you start sticking wires in this guy

 

[JelloIsJigglin]

If t10-l1 sympathetic innervation, then splanchnic blocks should work , no? Then move to drg if it the splanchnic sympathetic block worked

 

[painfree23]

so...people on here have suggested L5/S1 LESI, thoracic epidural, saddle block, S2 nerve block, TFESI (not sure what level), lumbar mbb, rectus adductor aponeurosis block, splanchnic block and DRGs at T10, L1, L2, S2-S4. and this is all after Pudendal, Genitofemoral, ilioinguinal, all failed. How many injections do you think this patient is going to take? steroid exposure? can we just admit we don't know what to do next..?

 

[Ducttape]

No becau$e that i$ $aying injection$ don’t work...

 

[gator2886]

so...people on here have suggested L5/S1 LESI, thoracic epidural, saddle block, S2 nerve block, TFESI (not sure what level), lumbar mbb, rectus adductor aponeurosis block, splanchnic block and DRGs at T10, L1, L2, S2-S4. and this is all after Pudendal, Genitofemoral, ilioinguinal, all failed. How many injections do you think this patient is going to take? steroid exposure? can we just admit we don't know what to do next..?

Well I appreciate the comment. Yes, I do not know what to do the next. The guy does not want his testicles removed. He is not seeking narcotics. He just wants his life back. I want to help him. Seems like this is a difficult area to treat.

 

[Orin]

The goal is to find the nerve to the generator. You shouldn't need steroids for that. Low volume, moderate concentration blocks.

You ain't figuring this out pontificating so walk down the list of possible targets or pass it along to your local academics if they're game.

 

[deleted875186]

Well I appreciate the comment. Yes, I do not know what to do the next. The guy does not want his testicles removed. He is not seeking narcotics. He just wants his life back. I want to help him. Seems like this is a difficult area to treat.

Interesting area to treat, after reading a about the innervation, if I were starting from scratch I would have tried truncal blocks first (ilioinguinal and gentofemoral block), if that failed or it was posterior scrotum pain than a pudendal, if that failed as noted above I would do a LSB to get the sympathetic fibers to see if this were the cause.

 

[Ligament]

so...people on here have suggested L5/S1 LESI, thoracic epidural, saddle block, S2 nerve block, TFESI (not sure what level), lumbar mbb, rectus adductor aponeurosis block, splanchnic block and DRGs at T10, L1, L2, S2-S4. and this is all after Pudendal, Genitofemoral, ilioinguinal, all failed. How many injections do you think this patient is going to take? steroid exposure? can we just admit we don't know what to do next..?

We can admit we don't know what to do, however;
1. OP has not given up, and asked for ideas. OP did not state they want to throw in the towel.
2. Steroids need not be used for any of these blocks.

 

[Baron Samedi]

TCA + pain psych

 

[painfree23]

We can admit we don't know what to do, however;
1. OP has not given up, and asked for ideas. OP did not state they want to throw in the towel.
2. Steroids need not be used for any of these blocks.

So no steroid...wat do u do when 3 out of the 7 blocks get 50% relief for a few hours?

 

[Ligament]

So no steroid...wat do u do when 3 out of the 7 blocks get 50% relief for a few hours?

Hydrodissect them, pulse them, continuous RF them, stim them, have them cut out. There are a number of options. We don't always have the luxury of being served a single pain generator to fix.

 

[epidural man]

We see a tremendous amount of groin/ball pain.

Although admittedly, now with robotic hernia repairs, it is a lot less.

Common mistake - you do the (named) block and then ask if pain is better.

First, you must document a technically successful nerve block. I find this is rarely done. You have a great block, AND they are numb but pain exists still, move to the next area. If they are not numb, repeat the same block.
Our typical pathway.

1. IL/IH block.

2. GFN block

3. T10-L2 SNRB. Imperative that technically successful block is documented. They should have groin/testicular numbness. Otherwise, you didn’t use enough local.

4. Pudendal.

5. sometimes will add at this point ganglion impar or caudal steroid.
If nothing has worked here, MRI LUMBAR spine to look at disc and facets as possible sources.

6. SCS (drg, high frequency, your choice)

 

[painfree23]

We see a tremendous amount of groin/ball pain.

Although admittedly, now with robotic hernia repairs, it is a lot less.

Common mistake - you do the (named) block and then ask if pain is better.

First, you must document a technically successful nerve block. I find this is rarely done. You have a great block, AND they are numb but pain exists still, move to the next area. If they are not numb, repeat the same block.
Our typical pathway.

1. IL/IH block.

2. GFN block

3. T10-L2 SNRB. Imperative that technically successful block is documented. They should have groin/testicular numbness. Otherwise, you didn’t use enough local.

4. Pudendal.

5. sometimes will add at this point ganglion impar or caudal steroid.
If nothing has worked here, MRI LUMBAR spine to look at disc and facets as possible sources.

6. SCS (drg, high frequency, your choice)

Do u individually block T10 T11 T12 L1 and L2 or just do them together?

 

[callmeanesthesia]

We see a tremendous amount of groin/ball pain.

Although admittedly, now with robotic hernia repairs, it is a lot less.

Common mistake - you do the (named) block and then ask if pain is better.

First, you must document a technically successful nerve block. I find this is rarely done. You have a great block, AND they are numb but pain exists still, move to the next area. If they are not numb, repeat the same block.
Our typical pathway.

1. IL/IH block.

2. GFN block

3. T10-L2 SNRB. Imperative that technically successful block is documented. They should have groin/testicular numbness. Otherwise, you didn’t use enough local.

4. Pudendal.

5. sometimes will add at this point ganglion impar or caudal steroid.
If nothing has worked here, MRI LUMBAR spine to look at disc and facets as possible sources.

6. SCS (drg, high frequency, your choice)

You’re doing SNRB before doing an MRI to look for anatomic cause of pain at those levels?

 

[epidural man]

You’re doing SNRB before doing an MRI to look for anatomic cause of pain at those levels?

I don't know...probably. I mean, if someone had a hernia repair, and continues to have pain - I usually suspect it was the surgery. But if they say they have the same pain that they had the surgery for (like a varicocele), then probably and MRI is better earlier in the course.

 

[epidural man]

Do u individually block T10 T11 T12 L1 and L2 or just do them together?

together. Usually just do T11-l2 though.

 

[deleted875186]

together. Usually just do T11-l2 though.

What is the purpose of doing a selective nerve root, you should get a dermatologist that covers it, but what next. Can’t RF a nerve root, pulsed radiofrequency not covered, could proceed to a DRG trial I suppose? Anything else yoj typically do?

 

[epidural man]

What is the purpose of doing a selective nerve root, you should get a dermatologist that covers it, but what next. Can’t RF a nerve root, pulsed radiofrequency not covered, could proceed to a DRG trial I suppose? Anything else yoj typically do?

Pulsed RF

 

[painfree23]

Pulsed RF

And patients are willing to pay cash for this??

 

[lobelsteve]

And patients are willing to pay cash for this??

I can do it for under $200

 

[epidural man]

Just take it out.

I’ve actually had patients that did this.

 

[Espn123]

I would definitely trial drg at t12-L1 before suggesting orchiectomy

 

[gator2886]

We see a tremendous amount of groin/ball pain.

Although admittedly, now with robotic hernia repairs, it is a lot less.

Common mistake - you do the (named) block and then ask if pain is better.

First, you must document a technically successful nerve block. I find this is rarely done. You have a great block, AND they are numb but pain exists still, move to the next area. If they are not numb, repeat the same block.
Our typical pathway.

1. IL/IH block.

2. GFN block

3. T10-L2 SNRB. Imperative that technically successful block is documented. They should have groin/testicular numbness. Otherwise, you didn’t use enough local.

4. Pudendal.

5. sometimes will add at this point ganglion impar or caudal steroid.
If nothing has worked here, MRI LUMBAR spine to look at disc and facets as possible sources.

6. SCS (drg, high frequency, your choice)

Thx epidural man. We probably should do MRI of thoracic spine and move up. I have not done that yet.. Urologist is ordering. Pretty much done everything else except for that and SCS

 

[Orin]

You can thermally ablate a thoracic or low sacral nerve root if you need to. Their motor contribution is relatively limited.

 

[deleted875186]

You can thermally ablate a thoracic or low sacral nerve root if you need to. Their motor contribution is relatively limited.

Do tell more, didn’t think you could RF something like T12 nerve root, doesn’t femoral have some component from T12?

 

[painfree23]

Do tell more, didn’t think you could RF something like T12 nerve root, doesn’t femoral have some component from T12?

Agree

 

[gator2886]

If I could find source I could pulse RF..He will pay for it. His insurance may even cover since we have tried so much other things. I appreciate all the tips, comments etc. The vast array of opinions does tell me we have some work to do on this particular area as a specialty

 

[Agast]

What about a superior hypogastric plexus block prior to stim? I would start coding him as CRPS if you are headed to stim/DRG, I haven’t seen plans cover pelvic pain.

 

[Orin]

Their motor contribution for T12 is limited to the lower extremity, but may be present in a small percentage of the population. I normally quote femoral as getting L1 at most, but more commonly L2-L4. Regardless, when you've got multiple DRGs contributing to a muscle though, I stress the loss of an individual nerve root less. It's something to counsel patients about for sure though

 

[painfree23]

Their motor contribution for T12 is limited to the lower extremity, but may be present in a small percentage of the population. I normally quote femoral as getting L1 at most, but more commonly L2-L4. Regardless, when you've got multiple DRGs contributing to a muscle though, I stress the loss of an individual nerve root less. It's something to counsel patients about for sure though

how do you counsel? do you say you may not be able to walk after this procedure?

 

[Orin]

how do you counsel? do you say you may not be able to walk after this procedure?

Yes.