Idiopathic Chronic Testicular Pain

Definition/diagnostic criteria Idiopathic chronic testicular pain (ICTP), also known as chronic orchialgia, is characterised by unilateral or bilateral testicular pain, lasting for more than three months, without an identifiable cause despite thorough evaluation.

Epidemiology ICTP is a significant urological problem, and is the reason for attendance in 2.5–5% of urology outpatients. It most commonly presents in men aged 18–50 years. Despite its prevalence, the condition is often underreported due to the private nature of the symptoms and the potential embarrassment it may cause.

Diagnosis
Clinical features: Patients with ICTP typically present with a persistent, intermittent or constant testicular pain that may be associated with symptoms such as heaviness or a dragging sensation. The pain may radiate to the groin, perineum or flank. Physical examination often does not reveal a definitive cause for the pain, and the testicular examination is frequently unremarkable.

Investigations: Investigations aim to exclude identifiable causes of testicular pain.

• Initial evaluation includes a thorough history and physical examination, urinalysis and scrotal ultrasound.
• Scrotal ultrasound is particularly important to rule out conditions such as epididymitis, testicular torsion or neoplasms.
• Further investigations, such as MRI or CT scans, may be considered in atypical cases or when initial imaging is inconclusive.

Typical abnormalities in ICTP are non-specific. However, the absence of findings such as testicular masses, signs of infection, or evidence of testicular torsion helps reinforce the diagnosis of ICTP.

Treatment The treatment of ICTP is primarily conservative. A multidisciplinary approach is recommended, including pain management, psychological support, and lifestyle modifications.

• Antibiotics are sometimes tried if there is doubt about whether there might be an underlying epididymitis.
• Pharmacological treatments include NSAIDs, with tricyclic antidepressants or anticonvulsants considered for neuropathic pain.
• In refractory cases, surgical options such as microdenervation of the spermatic cord or even orchiectomy may be considered, although these are generally seen as last-resort measures due to their irreversible nature and variable success rates.

Prognosis The prognosis for ICTP varies. While some patients may experience spontaneous resolution, others may have persistent, recurrent pain affecting their quality of life. Long-term management may be necessary for a significant proportion of patients. The chronic nature of the pain and its impact on daily activities and psychological wellbeing highlight the importance of a holistic, multidisciplinary approach to management.