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LETTER TO EDITOR
Year : 2012  |  Volume : 56  |  Issue : 3  |  Page : 315-316  

Treatment of post-operative orchialgia with therapeutic unilateral penile and spermatic cord block


Department of Anaesthesia, Bidar Institute of Medical Sciences, Bidar, Karnataka, India

Date of Web Publication20-Jul-2012

Correspondence Address:
Subodh S Kamtikar
Quarter #19, 3rd Floor, Doctors' Quarters, Bidar Institute of Medical Sciences, Bidar 585 401, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.98800

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How to cite this article:
Patil SG, Kamtikar SS. Treatment of post-operative orchialgia with therapeutic unilateral penile and spermatic cord block. Indian J Anaesth 2012;56:315-6

How to cite this URL:
Patil SG, Kamtikar SS. Treatment of post-operative orchialgia with therapeutic unilateral penile and spermatic cord block. Indian J Anaesth [serial online] 2012 [cited 2019 Nov 13];56:315-6. Available from: http://www.ijaweb.org/text.asp?2012/56/3/315/98800

Sir,

Chronic testicular pain is common and well recognized, but its pathophysiology is poorly understood. Non-invasive treatment techniques include drugs like non-steroidal anti-inflammatory drugs (NSAIDs), tricyclic antidepressants, gabapentin, carbamazepine and α-adrenergic antagonists. Minimally invasive techniques include Transcutaneous Electrical Nerve Stimulation (TENS) analgesia and pulsed radiofreqency of nerves. Transrectal periprostatic administration of lignocaine and methylprednisolone is reported in the literature for treatment of chronic orchialgia. [1] Spermatic cord block anaesthesia was also used successfully for this purpose. [2],[3] We describe a case of post-surgical orchialgia treated successfully with therapeutic penile block using 0.5% bupivacaine and methylprednisolone 40 mg/mL.

A 22-year-old male was referred to the pain clinic for complaint of burning pain in the testis and scrotum on the right side. This was not responding to NSAIDs like ibuprofen. He was operated for the ailment of spermatocoele on the right side. Right from the first post-operative day, he was having continuous burning sensation in the right testis and scrotum. This pain was not radiating to the left side or to the lower abdomen. Because of continuous pain, he was unable to do any work and lost his wages. His sexual desire was also adversely affected. Pain score on Visual Analogue Scale (VAS) of 0-10 was 9 on the affected side. His general and systemic examination revealed no abnormality. On local examination, the right testis and scrotum were tender. Scar of surgery was healthy. There was irregular swelling of size 4 mm × 4 mm on the right testis. There was no evidence of fluid in the scrotum. All investigations were within normal limits.

Along with NSAIDs, he was treated with oral Tramadol 50 mg BD, Carbamazepine 100 mg BD and Gabapentin 400 mg BD for 4 days without success. Then, it was decided to give interventional treatment with therapeutic block. Drugs used were 1 cc of 0.5% bupivacaine and 1 cc of methyl-prednisolone (40 mg/mL) taken in a single 2 cc disposable syringe. Under all aseptic precautions, 1.5 cc of the combination was injected on the right pubic tubercle. The spermatic cord was rolled between the fingers near the base of the scrotum and 0.5 mL of the drugs were injected around it. Immediately after injection, the pain score on VAS was 0. Prophylactic oral antibotic ciprofloxacin 500 mg BD was advised for 5 days. The patient was comfortable for the next 15 days. Again, after 15 days, he presented with the same complaints and had a pain score of 9 on VAS. Again, the therapeutic block as described above was repeated. Immediately after injection, the pain score on VAS was 0. This time, relief lasted for 2 months. Again, he presented with a pain score of 3 on VAS. It was treated with NSAIDs for 7 days, with the patient having complete relief.

Cause of post-operative orchialgia is injury to the nerves. This could be explained by the phenomenon of neural plasticity. In neural plasticity, disease or injury may result in changes at all levels of the nervous system, resulting in amplified pain messages. Another explanation of post-injury/surgery chronic pain syndromes is the development of sprouting between axons. This can occur either at the level of the dorsal root ganglion or at the dorsal horn. This results in light touch stimuli being re-routed into the pain pathway and felt as pain by the patient.

In the absence of any findings that require surgical treatment, conservative treatment is advised. [4] After initial measures like NSAIDs, tricyclic antidepressants and gabapentin fail, minimally invasive techniques are the next step.

Spermatic cord block anaesthesia using a local anaesthetic and a steroid like methylprednisolone can be used to treat this condition. [2],[3] Methylprednisolone acts by directly blocking the "C" fibres. [5] It also reduces the neurilemmal oedema. With repeated injections, the intensity of aberrant signals is brought down significantly and the condition becomes manageable with simple analgesics.

 
   References Top

1.Yamamoto M, Hibi H, Katsuno S, Miyake K. Management of chronic orchialgia of unknown etiology. Int J Urol 1995;2:47-9.  Back to cited text no. 1
[PUBMED]    
2.Fuchs E. Cord block anaesthesia for scrotal surgery. J Urol 1982;128:718-9.  Back to cited text no. 2
    
3.Issa M, Hsiao K, Bassel Y. Spermatic cord anaesthesia block for scrotal procedures in the outpatient clinic setting. J Urol 2004;172:2358-61.  Back to cited text no. 3
    
4.Heidelbaugh JJ, Llanes M, Weadock WJ. An algorithm for the treatment of chronic testicular pain. J Fam Pract 2010;59:330-6.  Back to cited text no. 4
[PUBMED]    
5.Johansson A. Methylprednisolone shortens the effects of bupivacaine on sensory nerve fibers in vivo. Acta Anaesthesiol Scand 1996;40:595-9.  Back to cited text no. 5
[PUBMED]    




 

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