Testicular Pain

[IHatePikeys]

Hey everybody, I'm new to posting, so I'm gonna see how much help all of you experts can be! 😀

I've got a nice 45 yo guy s/p orchiopexy for recurrent torsion, with testicular pain that's intermittent, lasting 15-25 minutes at a time, every other day. It's episodic, without aggravating/alleviating factors, but is disabling when it ocurs. It's definitely not radicular, and the dude is military trying to get back at it in Afghanistan.

Does anyone out there have anything to offer interventionally?

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[nvrsumr]

genitofemoral nerve block. If works consider pRF if that doesnt work consider peripheral nerve stim.

 

[IHatePikeys]

Yeah I've thought about that, you can pulse anything, really. Have you gotten good results with this?

 

[Ligament]

genitofemoral nerve block. If works consider pRF if that doesnt work consider peripheral nerve stim.

Agree. I've done these on a few patients so far. Has worked well, but my n is very small. Two weeks ago had an orchalgia patient, immediate and so far sustained relief from genitofemoral block with steroid.

Have pulsed the contents of the spermatic cord before, I don't recall if it worked.

 

[PMR 4 MSK]

Could it be the orchipexy failed or came loose? Or too tight?

 

[clubdeac]

Pulse DRG at T12/L1

 

[sweetalkr]

we see a LOT of pain with active duty guys

I was taught to do a splanchnic nerve block (T11) and RFTC at t10, t11, t12

the other guys sware by trying a Lumbar sympathetic block and impar ganglion block. but the guys i've seen, i end up doing a splanchnic rftc and genitofemoral cryo and getting at least 50%, although everyone is variable.

we've done a few SCS for testicular pain and they are hit or miss

 

[NEPain]

Everyone talks about how you can't bill for pulsed rf. So what are you doing? Do you eat the cost? Are you getting paid?
I agree that it is a nice technique for peripheral nerves (haven't done drg) but I stopped doing it when they stopped paying for it. How are you guys billing?

 

[Ligament]

Everyone talks about how you can't bill for pulsed rf. So what are you doing? Do you eat the cost? Are you getting paid?
I agree that it is a nice technique for peripheral nerves (haven't done drg) but I stopped doing it when they stopped paying for it. How are you guys billing?

Cash pay. I have one insurance which will cover it.

 

[epidural man]

Hey everybody, I'm new to posting, so I'm gonna see how much help all of you experts can be! 😀

I've got a nice 45 yo guy s/p orchiopexy for recurrent torsion, with testicular pain that's intermittent, lasting 15-25 minutes at a time, every other day. It's episodic, without aggravating/alleviating factors, but is disabling when it ocurs. It's definitely not radicular, and the dude is military trying to get back at it in Afghanistan.

Does anyone out there have anything to offer interventionally?

We see a TON of nut sack pain.

We try a ton of interventions for it.

Sometimes they work......wish they worked more.

diagnostic blocks first, if it works, then pulsed.

GFN...no, then TAP (ilioinguinal).... no, then T12-L2 (someone suggested T12-l1 - I think you should add L2) or a paravertebral at this level.

I have also seen impar block work, and a pudendal block.

SCS as mentioned is hit or miss. Try peripheral, or central, or lie in the gutter of T12-L2, or out the foramen.

It's not an easy problem to treat.

Calmare apparently gets nicely reimbursed. The data produced by the company is horrible (not the outcomes, the quality) but shows some ok outcomes for groin pain.

 

[epidural man]

Hey everybody, I'm new to posting, so I'm gonna see how much help all of you experts can be! 😀

I've got a nice 45 yo guy s/p orchiopexy for recurrent torsion, with testicular pain that's intermittent, lasting 15-25 minutes at a time, every other day. It's episodic, without aggravating/alleviating factors, but is disabling when it ocurs. It's definitely not radicular, and the dude is military trying to get back at it in Afghanistan.

Does anyone out there have anything to offer interventionally?

Honestly, nucynta works the best (n=2). 😀

 

[sweetalkr]

i have had 3 testicular pain follow ups in past week from when i first started (november 2011). all 3 had relief with splanchnic rftc. one guy had 40% and stopped ms contin. 2 other guys had over 60% with splanchnic and GF and Ilioinguinal RF/cryo.

colleague did stim for testicular and did not help. however another colleague it did help his pt.


i would definitely consider splanchnics because the embryologic origin..

 

[clubdeac]

i have had 3 testicular pain follow ups in past week from when i first started (november 2011). all 3 had relief with splanchnic rftc. one guy had 40% and stopped ms contin. 2 other guys had over 60% with splanchnic and GF and Ilioinguinal RF/cryo.

colleague did stim for testicular and did not help. however another colleague it did help his pt.


i would definitely consider splanchnics because the embryologic origin..

Sweets,
Hope your extended vacation is treating you well. Can you tell me where you target on the T10-12 vertebral bodies for your splanchnic RFs. Mid body in AP and superior inferior dimension?

 

[epidural man]

Hey everybody, I'm new to posting, so I'm gonna see how much help all of you experts can be! 😀

I've got a nice 45 yo guy s/p orchiopexy for recurrent torsion, with testicular pain that's intermittent, lasting 15-25 minutes at a time, every other day. It's episodic, without aggravating/alleviating factors, but is disabling when it ocurs. It's definitely not radicular, and the dude is military trying to get back at it in Afghanistan.

Does anyone out there have anything to offer interventionally?

Just did a pudendal block under CT for nut sack and perineal pain.

He was pain free immediatly after the injection, but they always are.

We will see how the diary comes back.

 

[sweetalkr]

club, it's hard work trust me 🙂 sometimes. it was cold yesterday. 67 degrees and I almost wore a sweater!

T11 is mid body in lateral, and i personally go just short of the anterior aspect of the vertebral body. i try to get in the lower 1/3 of the vertebral body at T10, and superior 1/3 of T12 all just shy of the anterior aspect of the vertebral body..

 

[clubdeac]

club, it's hard work trust me 🙂 sometimes. it was cold yesterday. 67 degrees and I almost wore a sweater!

T11 is mid body in lateral, and i personally go just short of the anterior aspect of the vertebral body. i try to get in the lower 1/3 of the vertebral body at T10, and superior 1/3 of T12 all just shy of the anterior aspect of the vertebral body..

Thanks man! Keep up the good work

 

[epidural man]

we see a LOT of pain with active duty guys

I was taught to do a splanchnic nerve block (T11) and RFTC at t10, t11, t12

the other guys sware by trying a Lumbar sympathetic block and impar ganglion block. but the guys i've seen, i end up doing a splanchnic rftc and genitofemoral cryo and getting at least 50%, although everyone is variable.

we've done a few SCS for testicular pain and they are hit or miss

What is RFTC?

Also, that seems crazy high for splanchnic blocks. I always did them at T12, sometimes top of L1. Is it different for groin pain? (I usually am doing it for cancer pain).

 

[101N]

Qutenza?

 

[sweetalkr]

just updating the post.

i called my old fellowship chairman and he explained the anatomy a bit more and i used it as a guide on my SCS for testicular pain. I admit I wasn't up to speed on the anatomy but it made more sense after he explained it to me.

essentially, if it is the skin of the scrotum, that's pudendal nerve so sacral stim will help more.
actual testicle itself usually is the splanchnics, so i placed my stim left lateral to midline with the tip of the lead at the inferior endplate of t10 and got total coverage of the left testicle. i like to trial with 2 leads since that is what i usually implant. i have changed and feel like the trial should be exactly like the implant. having said that, the other lead covered both testicles.

on a side note since we are talking about genitals, another patient I placed a stim in has had erectile dysfunction after an incomplete spinal cord injury. now he apparently has had complete resolution of ED. i placed the stim at bottom of t7 for low back/bilateral radicular symptoms. i know it is a bit common, but this is the first patient who has told me he had ED before and no problems after. FWIW