Is testicular pain coming from hip, pelvic or spinal musculoskeletal problems?

Ross Hauser, MD.

When we are contacted by men with undiagnosed or unknown sources of testicular pain, they usually describe situations that cause them great stress and anxiety and unfortunately great pain as well. If you are reading this article because you suffer from testicular pain or have been diagnosed with the more general term chronic scrotal content pain, you will see from case histories and clinical research that testicular pain is common. Below we present some of these stories that may have a very familiar tone to you because they sound a lot like your story.

One story is the short and to the point story: “I have chronic pain in my right testicle and lower back that gets worse with any strenuous physical or sexual activity.”

Some men have a story of a more prolonged medical history. “Eighteen months of pain in lower left back which radiates into front sacroiliac joint (SI) area, groin and thigh and testicle. I have been diagnosed with SI joint dysfunction and/or psoas muscle dysfunction. I had an MRI and nuclear bone scan, but neither revealed anything major wrong. I’ve had two steroid injections with temporary (less than a week’s relief). Physical therapy no help, Meloxicam no help, Naproxen no help.”

Some men show their frustration and the mental aspect of their testicular pain in their stories. “I am a former athlete with severe pain in the left groin region. The pain radiates around the lower left of my back. I also suffer from a burning sensation between my testicles and anal area, I have wet the bed at night on occasion but now urinating in bed is happening more frequently. I’ve seen so many doctors and cannot get any help. This has been life-changing physically and mentally I’m desperately looking for any type of help.”

Some men tell their story of managing with prednisone (anti-inflammatory) and gabapentin (nerve pain medication). “I am a mountain biker, weight lifter, occasional runner. I have had low back pain flares for about ten years, maybe twice a year that involve severe tenderness along my lower back on the pelvis bone and into the muscles. Pain has since returned and won’t resolve, became worse, and is now severe. I have referred pain to my right testicle, right upper thigh, and iliac crest area. (Inconclusive findings of) questionable narrowing at L5-S1. Now on Prednisone and gabapentin. They are providing some pain relief.”

Testicular pain that lingers without relief, despite numerous treatment attempts is sometimes labeled as “testicular pain of unknown origin.” The only treatment option available becomes pain management. This may involve the use of the previously mentioned anti-inflammatorynarcotic medicationscortisone injections into the spine or pubis.

Below we will look at research that seeks to pinpoint where pain may originate from in men diagnosed with undiagnosed testicular pain and the possible treatments and remedies for this problem. The focus of this article will be musculoskeletal origins for chronic scrotal content pain or testicular pain.

Article outline:

In 35 – 45% of patients, doctors cannot identify the source of chronic scrotal content pain or testicular pain, but there are a lot of names for it.

Of course, one of the frustrations of testicular pain is that these mens’ doctors do not know what is causing their pain. In 2019 doctors at the Mayo Clinic and Rush University wrote in Reviews in Urology (1): “The underlying etiology for Chronic scrotal content pain (including testicular pain) varies, and an obvious etiology is not readily identified (idiopathic) in 35% to 45% of patients presenting with chronic scrotal content pain. . . Chronic scrotal content pain also referred to as chronic testicular pain, chronic scrotal pain, chronic orchialgia, testalgia, and testicular pain syndrome, is characterized by pain or discomfort localized to the contents of the scrotum including the testicle, epididymis, and spermatic cord. To meet diagnostic criteria, the pain must be present for more than 3 months and interfere with activities of daily living.”

Chronic Scrotal Content Pain presents with a wide array of symptoms and many patients do not have reproducible findings on examination, suggesting alternative sources of pain

Now let’s look at an April 2023 paper in the journal Neurology (2) from doctors at the Mayo Clinic. In this study, the researchers reviewed the charts of 110 patients who came to the Mayo Clinic Alix School of Medicine, Department of Urology in Rochester, Minnesota for assessment of chronic scrotal content pain.

For the purpose of this article, we highlighted the musculoskeletal aspects of locating alternative sources of pain. Let’s have the Mayo Clinic doctors’ conclusion on this matter: ” Chronic Scrotal Content Pain presents with a wide array of symptoms and many patients do not have reproducible findings on examination, suggesting alternative sources of pain such as referred pain from musculoskeletal causes. The history and physical examination should include assessments for concurrent abdominal, back, hip, and other genital/pelvic pain that may suggest alternative diagnoses and referrals for appropriate treatment.”

Conservative care treatments high failure rate – While conservative therapy has almost always been considered first-line treatment, success is relatively poor ranging from 4.2% to 15.2% in some studies

In a May 2023 update in Stat Pearls (3) (Stat Pearls is a publication of the National Center for Biotechnology Information, U.S. National Library of Medicine) from the Creighton University School of Medicine, doctors write: “Conservative therapy includes heat, ice, scrotal elevation, antibiotics, analgesics, NSAIDs, antidepressants (doxepin or amitriptyline), anticonvulsants (gabapentin and pregabalin), regional and local nerve blocks, pelvic floor physical therapy, biofeedback, acupuncture, and psychotherapy for at least 3 months.

While conservative therapy has almost always been considered first-line treatment, success is relatively poor ranging from 4.2% to 15.2% in some studies.”

A September 2023 paper in Therapeutic Advances in Urology (4) writes: “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.” In other words, we are back at the surgical option.

Half the men who had microsurgical spermatic cord denervation suffered from idiopathic chronic orchialgia (testicular pain)

In the above paper, a little over 1 in 5 men were sent to microdenervation surgery. A March 2021 paper published in the journal Urology (5) examined factors that could help predict which men would have failed microsurgical spermatic cord denervation for chronic orchialgia.

Here the charts of one hundred and five men who underwent microsurgical spermatic cord denervation were reviewed. Of those, 38 were bilateral (77 patients had one side testicular pain) for a total of 143 testicular treated.

Surgical outcomes:

Pre-surgery patients were diagnosed as having pain caused by:

To review: Half the men who had microsurgical spermatic cord denervation suffered from idiopathic chronic orchialgia (testicular pain).

Is it testicle pain or a hip labral tear?

A December 2020 paper in the journal Urology (6) examined the charts of ten men, average age of 51, and with an average median duration of chronic orchialgia pain of about 10 months. MRI was obtained after testis pathology was ruled out. Pain was noted in the groin (100%) and hip (50%). Hip MRI identified overt hip labral tears in 8 men (10/12 hips evaluated, 83%) and labral fraying in the remaining 2 (16.7%).

Following MRI, five of the men had a steroid and local analgesic hip injection. Two of the men reported lasting resolution or significant improvement in pain (2 men; 80%, follow-up 3-15 months). Two men had complete resolution of pain with 8 weeks of physical therapy.

The authors concluded: “Hip MRI has a high rate of diagnosis of labral tear in appropriately selected men referred to the urologist for chronic orchialgia. Identification of orthopedic pathology may avoid unnecessary antibiotics, opiates, or urological surgery.”

In a May 2021 paper in the journal Research and Reports in Urology (7), researchers reviewing current standard practices of care for chronic scrotal pain, in discussing physical therapy, authors noted: “Up to 10% of patients, who present with chronic scrotal pain, are found to have musculoskeletal pain localized to areas that may include the conjoint tendon, the adductor tendon and the pelvic floor. Because of this, patients may benefit from physical therapy such as perineal/pelvic floor exercises. Due to the relative ease of this method, together with its absence of side effects, this should be a first-line option, ideally in conjunction with other non-surgical options. . . ”

Restless legs syndrome and chronic testicular pain

In May 2022, doctors reported in the Journal of Clinical Sleep Medicine (8) of a possible connection between Restless legs syndrome and chronic testicular pain. Restless legs or leg syndrome, the constant movement of the legs (the legs are “restless”) that occurs mostly and night and causes insomnia and sleep disturbances, is seen in chronic testicular pain. In this paper the researchers presented a case history: “In this case report, the patient presented at the sleep clinic with a chief complaint of insomnia and the classical symptoms of Restless legs syndrome. He also mentioned chronic testicular pain. For over a year, the patient had undergone urologic investigation and empiric treatments (typically those treatments mentioned above, some with a specific focus on a possible bacterial infection), with only mild improvement of the testicular pain. After three months of therapy with pramipexole (a drug commonly given for the treatment of restless leg syndrome and Parkinson’s disease), the Restless legs syndrome symptoms and the chronic testicular pain were no longer present.” The researchers concluded: “Finding an etiology for chronic testicular pain can be challenging and many cases are diagnosed as idiopathic (unknown cause). Restless legs syndrome may be a forgotten and unidentified etiology for chronic testicular pain in typical urological care.” The suggestion is that urologists may be overlooking Restless legs syndrome as a cause of chronic testicular pain.

Genitofemoral nerve entrapment at the psoas muscle

In October 2017, doctors at the University of St. Augustine for Health Sciences (9) presented a case study on a patient who had a successful treatment outcome because he was correctly diagnosed with orchialgia symptoms from genitofemoral nerve entrapment at the psoas muscle.

The genitofemoral nerve travels through the psoas muscle and then divides into a genital and a femoral component. The genital component also known as the external spermatic nerve innervates the scrotum area. The entrapment at the psoas muscle can cause pain in the testes and the front and side of the thigh. Testicular pain can occur due to irritation of the genitofemoral nerve at L1/L2 or hypertonicity of the psoas major muscle.  The combination of spinal mobilization and manual psoas stretching might have helped relieve the entrapment resolving the patient’s symptoms.

Pelvic Floor Dysfunction

In 2010, doctors at Leiden University Medical Center in The Netherlands (10) examined the association between chronic testicular pain and pelvic floor overactivity or dysfunction. In our practice, we have seen patients with pelvic floor dysfunction causing symptoms of back pain, pain in the genital region including the testicles, hip pain, and in some instances the coccyx or tailbone area.

In the research presented above from Leiden University, doctors looked at 41 patients with chronic testicular pain. All the patients underwent standard pelvic floor investigation, including history using a standardized questionnaire and Electromyography (to test the resting tone of the pelvic floor muscles and thereby pain intensity). In the questionnaire, patients were asked about complaints in 3 domains ((micturition (the ability to urinate), defecation (the ability to have a bowel movement), and sexual function)) suggestive of pelvic floor dysfunction.

Results: The average patient age was 48 years old.

The researchers concluded: “Chronic testicular pain can be a symptom of pelvic floor overactivity, especially in younger patients. A diagnostic evaluation should be performed when no pathophysiology can be found.”

Is testicular pain coming from spinal problems?

Referral pain, meaning problems in the spine that affect the nerves of the genitals is not a new idea. It is however getting more attention because of the number of failed procedures surrounding both back pain and testicular pain. Back in 2003, researchers at the University of Southern California noted (11) that “Unsuccessful recognition of the origin of testicular pain and a high failure rate of surgical interventions lead to poor outcomes, psychologic distress, and increased costs of care. A frequently overlooked cause of testicular and buttock pain is irritation of the T10-L1 sensory nerve roots, the genitofemoral nerve (genital sensory nerve), and the ilioinguinal nerve (which runs between T12 and L1).” The genitofemoral nerve supplies sensation to the skin of the front scrotal area and upper thigh area. Its travels start at the L1-L2, through the psoas major muscle.

Even, when there is no back pain, spinal problems should be considered. A 2013 French paper (12) suggested, “After excluding a urological or gastrointestinal cause, referred pain of musculoskeletal origin should be considered, even in the absence of back pain. Described by Dr. Robert Maigne, this referred pain originates from a minor intervertebral dysfunction of the thoracolumbar junction. Imaging of the spine is not helpful. Rather, the diagnosis is made by seeking pain triggered by the mobilization of the lumbar vertebrae.”

Nerves running through pelvis

Thoracolumbar syndrome is a problem of spinal instability causing pressure on the superior cluneal nerves. Symptoms can include low back pain, sacroiliac pain, hip pain, groin pain, and testicular pain. A February 2020 paper in the journal Progress in Urology (13) investigated the effectiveness of osteopathic diagnosis and treatment of thoracolumbar syndrome for chronic testicular pain.

Men suffering from testicular pain and diagnosed with thoracolumbar dysfunction were prescribed 1 to 3 osteopathic manipulation treatment sessions, usually at weekly intervals. Treatment success was evaluated using the Visual Analog Scale (Pain scale 0 – 10) and long-term effectiveness was assessed by regular follow-up.

Chiropractic care 

In an August 2020 case history presented in the American Journal of Men’s Health (14), Dr. Eric Chun Pu Chu of the New York Chiropractic and Physiotherapy Centre in Hong Kong describes a case of testicular pain resolved with chiropractic care. He writes: “Degenerative disease of the lumbar spine is often ignored as a potential cause of testicular pain because the exact link between the two remains uncertain. This article reports the case of a 60-year-old man with a 3-year history of low back pain and unexplained right testicular pain for 2 years. . . . After failure to achieve pain relief through multiple types of therapy, the patient sought chiropractic treatment for his condition. Lumbar spine magnetic resonance imaging (MRI) revealed disc protrusion at the L1/L2, L3/L4, and L4/L5 segments causing thecal sac indentations (in simple terms, compression on the spinal cord).” Dr. Chun Pu Chu noted in this patient that there was no obvious cause of direct testicular (no abnormalities could be identified). Therefore his chronic testicular pain had lumbar disc disease origins. The patient’s outcome was regular improvement in his lower back and testicular pain with complete resolution of both after 8 weeks of chiropractic treatment.

In June 2021 Dr. Chun Pu Chu described another case of chronic orchialgia (scrotum contents pain including the testicles) in the American Journal of Men’s Health (15). Dr. Chun Pu Chu writes that  chronic orchialgia is a common problem but “has seldom been described in association with lumbar discogenic disease.” In this case, a  39-year-old sports coach had low back pain, disc protrusions at L3/L4 and L4/L5 levels right (testicle side) orchialgia, and sciatica that was not responding to conservative management. In this patient “Positive outcomes in relieving back and testicular pain were obtained after a total of 30 chiropractic sessions over a 9-week period.” While chronic orchialgia is not an uncommon problem for men of all ages, it has seldom been described in association with lumbar discogenic disease. The current study provided preliminary support for a link between orchialgia and lumbar disc herniation. Chiropractic manipulation provided a mechanistic alleviation of noxious lumbar stimuli, leading to symptomatic and functional improvements.

Lumbar nerve stimulation

In July 2023 doctors at the University of Vermont Medical Center presented this case study in the journal Cureus (16). It’s the story of a 33-year-old man with right-sided scrotal pain. The doctors observed that this patient had no significant past medical history. His pain started three years earlier without obvious cause. The patient complained of a 4/10 pain on Numerical Rating Scale (0 – 10), and increased to 10/10 with minimal activity.

If the patient held his urine or did heavy lifting, he felt pain. He also felt pain during ejaculating. He also reported some difficulty obtaining an erection as well as a decline in libido, despite a normal testosterone level. He started taking tadalafil (Cialis) 5 mg daily one year before coming in for treatment, which helped in decreasing scrotal pain.  The patient was also using ibuprofen/acetaminophen as needed, methocarbamol 750 mg tablet three times daily, and naproxen 500 mg two times daily as needed with minimal improvement in pain. He previously had a spermatic cord block, performed by urology, which did not provide any pain relief. The patient was then scheduled for an L2 (lumbar nerve stimulation) peripheral nerve stimulator. He was seen two months after the procedure for the lead removal and reported 1/10 pain and reported significant functional improvement in his activities of daily living. The patient was subsequently followed up at five months and did not report testicular pain at that visit.

In one case history (17) doctors at Bridgewater State University reported on a case in the Journal of Athletic Training of an athletic 49-year-old male who suffered from chronic non-traumatic testicular pain. The cause of his problems was undiagnosed Sacroiliac Joint Dysfunction which caused pressure on the pudendal nerve that runs through the pelvis and affects the genitals.

Pulsed radiofrequency

Researchers suggest that one minimally invasive treatment of chronic orchialgia, scrotum, and testicular pain is pulsed radiofrequency. The authors of this December 2022 paper in the journal Diagnostics (18) write: “The perspective on treating chronic orchialgia clearly shows that the main advantage of pulsed radiofrequency from surgical denervation procedures is that this is a minimally invasive technique with no adverse effects. Pulsed radiofrequency does not damage the nerve.” Citing the work of other researchers the authors continued: “(researchers) performed PRF procedures on three different peripheral nerves—ilioinguinal, iliohypogastric, and genital branches of genitofemoral—and showed excellent pain relief at six months. However, using PRF on nerve roots requires fluoroscopic imaging and precise needle positioning and is usually preceded by diagnostic nerve root blocks.” They note that an advantage now becomes a challenge. In this situation, the main disadvantage of the use of pulsed radiofrequency is it is operated dependently (the need for other procedures).

Iliolumbar ligament injury and testicular, groin pain

What are we seeing in this image?

The complexity and interwoven nature of the sacroiliac ligaments and the iliolumbar ligaments. The iliolumbar ligaments help keep the two halves of the pelvis in alignment. Damaged iliolumbar ligaments cannot do this job and impact the sacroiliac joints.

Iliolumbar ligament sprain should be considered for any unexplained vaginal, testicular, or groin pain

Generally, these pains can be reproduced when the ligaments around the pelvis are palpated. The most commonly affected areas are the ligaments around the sacrococcygeal junction, which includes the sacrococcygeal ligament, sacrotuberous, and sacrospinous ligaments. Since these ligaments are near the rectum, it makes sense that rectal or groin pains originate from these structures. When Prolotherapy has strengthened these ligaments, chronic rectal pain dissipates. Another common cause of chronic groin, testicular, or vaginal pain is iliolumbar ligament weakness because this ligament refers to pain from the lower back to these areas. Prolotherapy of the iliolumbar ligament can be curative for chronic groin, testicular, and vaginal pain, and symptoms associated with pelvic floor dysfunction

Sometimes we see patients who have been to other healthcare providers who offer various single-inject treatments. This can include a cortisone injection or a Platelet Rich Plasma injection. We will discuss these more below. At this point, we want to first bring in the evidence that successful treatment may require much more than a single shot of anything.

Prolotherapy treatment strengthens the ligaments and damaged entheses of the iliolumbar ligaments

The first step in determining ligament laxity or instability is by physical examination.12 The examination involves maneuvering the patient into various stretched positions. If weak ligaments exist, the stressor maneuver will cause pain.

In the illustration above you can see how the iliolumbar ligament plays an important biomechanic role in anchoring the spine to the pelvic ring. Doctors in Ireland describing the possibility of using various injection techniques to treat Iliolumbar Syndrome in the medical journal Pain Physician (19also offered a good summary of the importance of the iliolumbar ligament. They wrote:

In Prolotherapy treatments, we know that we need to find the source of pain and instability. A Prolotherapy injection at this site and the work of the anesthetic in the solution can tell us immediately if we have found the spot because the patient has immediate pain relief.

Prolotherapy can stimulate the healing of unresolved testicular pain by repairing injured ligaments that may be referring to pain in the testicles or groin. It works by initiating a mild inflammatory response in the treated area (i.e. the iliolumbar ligament), which attracts immune cells to heal the structure(s) in that area. With time and multiple treatments, patients usually notice a gradual decrease in testicular pain as injured tissues continue to heal. In more severe cases, the entire pelvic floor is involved and needs treatment (including the pubis, ischial tuberosities, and coccyx). Once the weak tissues have been identified and treated with Prolotherapy, chronic testicular pain usually subsides.

Pudendal Nerve Entrapment Syndrome: Under diagnosed and inappropriately treated

References 

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This article was updated November 14, 2023

 

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