Chronic testicular pain (Orchialgia) represents a management dilemma. Initial treatment is usually nonsurgical. When conservative treatment fails, next therapy is unclear. We present a case with worsened pain after surgery and improvement after a S3 transforaminal epidural steroid injection (TFESI).

Case

Patient is a 38-year-old man with a year history of left testicular pain. He was diagnosed with epididymitis and treated with antibiotics improving his pain for a short period. Local anesthetic injections into the epididymis also failed to provide long term relief. He then went for a left epididymectomy and vasectomy, without improvement. On his first visit to our clinic, pain was in the left scrotal area and perineum. We performed a left S3 TFESI which resulted in 80 % reduction of his pain.

Discussion

Pain in the testis and epididymes is mediated by fibers carried in the genital branch of the genitofemoral and ilioinguinal nerve. Spermatic cord block or blockade of the genitofemoral and ilioinguinal nerve should relieve the pain. But, there are patients who do not respond to these blocks (5). The ability to abolish testicular pain by periprostatic application of local anesthetic is consistent with the pelvis plexus supplying neural input to the testis (6).

Pelvic plexuses are formed by a continuation of the hypogastric plexus, the sacral sympathetic efferent fibers from the second, third, and fourth sacral nerves, and a few filaments from the first two sacral ganglia. Knowing this, we decided to try a S3 (third sacral nerve) TESI to relief his pain. Patient had almost complete resolution of his pain that had persisted for more than 6 months.

Summary

After factors of chronic testicular pain have been rule out and conservative treatments failed. A sacral (2-3) TFESI could provide an important diagnostic and or therapeutic tool for treatment of refractory orchialgia.