10019

Pediatric Chronic Orchalgia

Sunday, October 3, 2010: 2:48 PM
Yerba Buena Salon 9 (San Francisco Marriott Marquis)
Jonathan F. Kalisvaart1, Bruce Broecker1, Wolfgang H. Cerwinka1, Scott Cuda1, James Elmore1, Jonathan Kaye1, Andrew J. Kirsch1, Charlotte A. Massad1, Hal C. Scherz1, Claudia Y. Venable2 and Edwin A. Smith1, (1)Pediatric Urology, Emory University School of Medicine, Atlanta, GA, (2)Childrens Healthcare of Atlanta Center for Pain Relief, Atlanta, GA

Purpose: Chronic orchalgia represents a frustrating and debilitating problem.  Defined as intermittent or constant testicular pain lasting >3 months and interfering with normal daily activities, this subset of orchalgia has been neglected in the pediatric literature.  We describe our experience with diagnostic studies and treatment of the pediatric chronic orchalgia patient.

Methods: Charts were screened for patients seen from 2007-2010 to identify patients with a diagnosis of scrotal or testicular pain. Diagnoses found included orchalgia, testicular torsion, appendix testis torsion, and disorders of the male genitalia NOS. The records of patients meeting the criteria of chronic orchalgia were further reviewed to record the elements of the history and physical exam, diagnostic tests, treatment and outcomes.

Results: 982 patients were identified who had a diagnosis of scrotal or testicular pain. Of these, 65 met the criteria for chronic orchalgia. The mean age was 13 years (range 2-18) and mean duration of pain was 8.6 months (range 3-48 months). Physical exam findings were normal in 46 (70%). (Figure 1)  U/S findings included small hydroceles (8), varicoceles (7), epididymal cysts (5), testicular microlithiasis (3) but did not lead to operative intervention in any patient.  59 patients were managed conservatively with analgesics and supportive measures. Of these, 36/59 (61%) did not return for follow-up, 10/59 (17%) were better on follow-up and 13/59 (22%) either had minor improvement or no change.  Five of the non-responding patients were managed by the anesthesia pain service.  One responded to clonidine and 4 received epidurals with or without additional pain medications with 3 experiencing significant pain improvement.  One patient is currently undergoing psychiatric evaluation.

Conclusion: Pediatric chronic orchalgia is an often encountered problem with little guidance for management appearing in the literature.  Imaging does serve the purpose, in the acute setting, of ruling out acute torsion and in the chronic setting of reassuring the patient that there is nothing wrong, but did not seem to change the management of our patients.  Conservative management allowed symptoms to subside in the majority of cases.  Based on our experience we recommend that patients be treated initially with conservative measures for 1-2 months. Failures benefit from early involvement of the anesthesia pain management service who are able to offer treatment modalities applicable to chronic pain conditions. Epidural anesthesia appears to be a viable option for treatment of refractory cases. Surgical management in the face of a normal physical exam and imaging does not seem to have a role.

Figure 1: Physical exam findings

Finding

N=65

Laterality of pain

Left: 21 (32%)

Right: 6 (9%)

Bilateral: 35 (54%)

Unknown: 3 (5%)

Physical Exam Findings

Normal: 46 (71%)

Varicocele: 6 (9%)

Cyst, spermatocele or hydrocele: 5 (8%)

Other epididymal abnormality: 2 (3%)

Other testicular abnormality: 3 (5%)

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