Chronic scrotal pain – not related to vasectomy

Introduction

It happens – although very rarely – that some time after the procedure (sometimes even several years later), patients call me after a vasectomy reporting the appearance of pain.

I always invite such patients to the office for a consultation and examination, but first I take a history over the phone and, if needed, order a few tests or consultations – urological or orthopaedic.

So far, it has always turned out that the cause of the pain was something other than the vasectomy. Since 2013, I have not recorded a single case of chronic pain after a vasectomy.

The article below explains, in an accessible way, what chronic scrotal pain is (most often unrelated to any procedure), what its causes may be (other than vasectomy), how the diagnostic process works, and what treatment options are available. This information will help you better understand the symptoms and prepare for a conversation with your doctor.

Robert Kulik, January 2026 (updated: September 2026)

What is chronic scrotal pain?

Chronic scrotal pain (in medical terminology also called chronic testicular pain, orchialgia or testicular pain syndrome) is pain or discomfort felt within the scrotum that persists for at least 3 months and disrupts the patient’s daily functioning (you cannot concentrate on everyday activities because it hurts all the time).

The pain can be located in various structures within the scrotum:

• in the testicle
• in the epididymis (the structure adjacent to the testicle, responsible for the maturation and storage of sperm)
• in the spermatic cord (the structure connecting the testicle to the abdominal cavity)

This kind of pain can significantly affect quality of life – both physical and mental well-being, as well as sexual life. Patients often also feel anxiety related to the fear of a serious condition.

Important information: chronic scrotal pain is a common problem. Complaints of this type account for 2-5% of all visits to urology offices.

How do the nerves in this region work?

Understanding the anatomy of the nerves in the scrotal region helps explain why the pain can be so troublesome and where it may come from.

The scrotum and its contents are innervated by nerves originating from different levels of the spine:

• The genitofemoral nerve – originates from the lumbar spine (level L1-L2). It is responsible for sensation in the front and side of the scrotum and for the cremasteric reflex (raising of the testicle).
• The ilioinguinal nerve – also from the lumbar region (L1). It innervates the base of the penis, the upper part of the scrotum and the inner surface of the thigh.
• The pudendal nerve – originates from the sacral region (S2-S4). It innervates the back of the scrotal skin, the perineum and the penis.
• The vasal nerves – they are scattered throughout the spermatic cord and play the main role in conducting pain in chronic complaints.

Spinal nerve compression – the most common cause of referred pain

Statistically, the most common cause of pain radiating to the scrotum is compression of spinal nerves in the lower spine. Before looking for serious diseases, it is worth ruling out this simple and often easily treatable cause.

As the list above shows, all the main nerves innervating the scrotum and its contents originate from the lower spine – from the lumbar level (L1-L2) and the sacral level (S2-S4). This means that any problem in the lumbosacral spine can produce pain felt in the scrotum, groin or testicles – even if the testicles themselves are perfectly healthy.

Sciatica (ischialgia) is the classic example of such referred pain. It occurs when the nerves exiting the spine are compressed – most often by:

• a herniated or bulging intervertebral disc (discopathy)
• spinal canal stenosis
• degenerative changes of the spine
• tense paraspinal muscles

Spinal nerve compression can cause pain radiating to the groin, scrotum, testicles, penis, as well as to the buttocks and lower limbs. Importantly – the pain may be felt exclusively in the scrotum, without accompanying back pain, which often misleads patients.

The good news: many cases of spinal nerve compression can be effectively treated with simple methods:

• Posture correction – sitting properly, avoiding staying in one position for long periods, trousers loose at the waist. Squeezing a protruding belly with a belt causes an abnormal flattening of the lumbar lordosis, which can cause pain. If you have a protruding belly – swap your belt for braces!
• Weight reduction – excess weight puts a significant load on the lumbar spine
• Core-strengthening exercises – strong abdominal and back muscles relieve the spine
• Stretching – regular stretching exercises reduce muscle tension
• Physiotherapy – professional rehabilitation can bring significant relief

So before you start worrying about serious diseases, it is worth first ruling out these simple causes and trying the basic treatment methods.

Why is chronic pain different from acute pain?

Acute pain (e.g. after an injury) is a simple mechanism: a painful stimulus activates receptors, which send a signal to the brain, and we feel pain. Chronic pain is much more complicated.

With prolonged irritation, a phenomenon called central sensitisation can occur. This means the nervous system becomes overly sensitive – it starts to respond with pain to stimuli that normally should not be painful (allodynia), or it responds with excessive pain to ordinary stimuli (hyperalgesia). It is a bit like a car alarm that has become so sensitive that it goes off even at a light gust of wind.

What does this mean for treatment? If central sensitisation has occurred, removing the original cause of the pain alone may not be enough. Sometimes additional treatment aimed at “resetting” the oversensitive nervous system is necessary.

What can cause chronic scrotal pain?

The causes of chronic scrotal pain are very diverse. Importantly – in about 35-45% of patients, no clear cause can be established. This is so-called idiopathic pain (of unknown cause). However, this does not mean the pain is not real or that it cannot be treated!

Causes directly related to the testicle and epididymis

1. Epididymitis and orchitis (epididymo-orchitis)

It can be caused by bacteria or viruses. In acute inflammation there is sudden pain, swelling, redness and increased temperature of the scrotum. Elevating the testicle often brings relief (the so-called positive Prehn’s sign). Most cases resolve after anti-inflammatory treatment and possibly antibiotics within a few weeks. However, in some patients, discomfort after inflammation may persist for 6 weeks or longer. Not related to a previous vasectomy.

2. Non-infectious epididymitis

It can be caused by urine refluxing through the ejaculatory ducts. In such cases the doctor may recommend additional tests for urethral stricture or other abnormalities. Not related to a previous vasectomy.

3. Epididymal cysts (spermatocele)

These are benign, fluid-filled formations that can cause a feeling of discomfort or heaviness. They are clearly visible on ultrasound. Not related to a previous vasectomy.

4. Testicular tumours

Although testicular tumours more often present as a painless lump than as pain, they must always be ruled out in the diagnostic process. When a tumour is suspected, an ultrasound examination, blood tumour markers and imaging of the abdomen and chest are performed. Not related to a previous vasectomy.

5. Henoch-Schönlein purpura (HSP)

A rare but important cause of scrotal pain, especially in younger patients (under 20 years of age). It is a systemic vasculitis with the highest incidence at the age of 4-5 years. Scrotal involvement occurs in 2-38% of cases and can be misdiagnosed as an acute problem requiring urgent surgery. Characteristic signs are significant scrotal swelling with preserved normal blood flow in the testicles, an enlarged epididymis and a hydrocele. Not related to a previous vasectomy.

Causes related to the spermatic cord (higher in the scrotum, but outside the testicle)

1. Varicocele

This is a dilation of the veins draining blood from the testicle – comparable to varicose veins of the legs, except that they occur in the scrotum. Varicoceles can cause a dull pain that worsens with exertion and subsides when lying down. They are more common on the left side due to the anatomy of the venous drainage (this is the case in every man). Not related to a previous vasectomy.

Note: newly appearing varicoceles, especially on the right side, in an adult man require ruling out a tumour in the abdominal cavity or retroperitoneal space that may be compressing the veins draining blood from the testicle.

2. Pain related to previous operations

• after inguinal hernia surgery
• after hydrocele surgery
• after varicocele surgery
• after childhood surgery for an undescended testicle
• post-vasectomy pain syndrome (PVPS) – discussed in a separate article

Extrascrotal causes (referred pain, pain radiation)

Interestingly, pain felt in the scrotum may actually originate from a completely different place. This is due to foetal development – the testicles originally form in the abdominal cavity and only later descend into the scrotum, retaining their innervation from higher levels.

1. Prostate diseases

Up to 50% of cases of prostatitis can produce complaints felt in the testicles as referred pain (pain radiation). Not related to a previous vasectomy.

Why does a diseased prostate hurt in the scrotum? This phenomenon is based on three main mechanisms.

Pain radiation from the prostate. This is the most important mechanism. The prostate and the testicles share innervation from the same spinal cord levels (mainly segments T10-L1 and S2-S4). When the prostate is inflamed, pain signals flow to the spinal cord. The brain receives information from the same nerve “junction” that the nerves from the scrotum also reach. An error of interpretation occurs – the brain “projects” the pain onto the testicle, even though the testicle itself is healthy.

Central sensitisation. In chronic prostatitis, the neurons in the spinal cord become overreactive. As a result, even normal stimuli from the perineal region (e.g. touch, the movement of the testicle while walking) are interpreted as severe pain. This is a mechanism characteristic of CPPS (Chronic Pelvic Pain Syndrome).

Pelvic floor muscle tension. Prostatitis often leads to a reflexive, protective spasm of the pelvic floor muscles (including the levator ani). Chronic spasm of these muscles can compress the pudendal nerve and the genitofemoral nerve. Irritation of these nerves produces a piercing pain radiating directly to the scrotum. More about this mechanism in point 9.

Feature	Pain of testicular origin	Pain referred from the prostate
Touching the testicle	Clearly intensifies the pain	The testicle is often not tender on examination
Accompanying symptoms	Swelling, redness of the scrotum	Problems with urination, pain after ejaculation
Character of the pain	Sharp, localised	Dull, diffuse, radiating to the groin

Comparison table: testicular pain vs pain referred from the prostate

2. Cycling (very intensive)

Years of long training rides with a poorly chosen saddle sometimes lead to ischaemia-related changes within the testicle. Such changes are usually permanent and irreversible. Not related to a previous vasectomy.

One of the publications, “US findings in the scrotum of extreme mountain bikers”, describes the pathomechanism and structural changes. This publication is key because it is one of the few that analyses changes inside the scrotum in cyclists in such detail. The study included 85 mountain bikers and 31 controls (men who do not cycle).

Pathomechanism: chronic microtrauma. The authors explain that the pain and changes do not result from a single impact but from so-called subclinical microtraumatisation. This mechanism consists of:

• compression (pressure) – the constant pressure of the saddle on the perineum and the blood vessels supplying the testicles
• vibrations and shocks – riding on rough terrain generates repeated impacts transmitted to the soft tissues of the scrotum
• friction – it causes microscopic damage to the coverings of the testicle and epididymis

Imaging changes in intensive cyclists:

Change	Frequency in cyclists	Description and background
Epididymal calcifications	40%	The result of chronic inflammation. Fibrous tissue replaces the damaged cells and then mineralises.
Scrotal calculosis	81%	So-called “scrotal pearls” (scrotoliths). Free bodies in the cavity of the tunica vaginalis, formed by the deposition of calcium salts on desquamated cells or micro-haemorrhages.
Hydroceles	28%	Accumulation of serous fluid as a result of reactive inflammation of the coverings caused by friction and pressure.
Epididymal cysts	46%	Dilation of the efferent ductules, often associated with mechanical obstruction caused by microtrauma and scarring.

3. Ureteral stones

A stone in the ureter can cause severe pain radiating to the scrotum, accompanied by urinary symptoms (frequent urination, urgency, blood in the urine). Not related to a previous vasectomy.

4. Inguinal hernia

A protrusion of tissue through the inguinal canal can cause pain in the groin and scrotum, especially with exertion. Not related to a previous vasectomy.

5. Spinal diseases and spinal nerve compression

This is statistically the most common cause of pain referred to the scrotum. Discopathy, sciatica, spinal canal stenosis – the pain may be felt mainly or exclusively in the scrotum, without back pain. The mechanism and treatment are described in detail above, in the section on nerves. Not related to a previous vasectomy.

6. Hip joint diseases

Degenerative changes or injuries of the hip joint can also manifest as pain in the groin and scrotum. Not related to a previous vasectomy.

7. Abdominal vessel aneurysms

In rare cases, an aneurysm of the abdominal aorta or iliac arteries can cause pain referred to the scrotum. Not related to a previous vasectomy.

8. Retroperitoneal tumours

Tumours located in the back part of the abdominal cavity can compress nerves and cause pain felt in the scrotum. Not related to a previous vasectomy.

9. Pelvic floor muscle tension and pudendal nerve compression

This is a common but underappreciated cause of scrotal pain. The pelvic floor muscles (levator ani, obturator internus, bulbospongiosus) can be chronically tense or contain painful trigger points. Testicular pain is reported by almost 50% of patients with chronic pelvic pain related to muscle tension. Not related to a previous vasectomy.

How does a tense muscle compress a nerve? The pudendal nerve runs through narrow spaces: between the sacrospinous and sacrotuberous ligaments and through Alcock’s canal in the fascia of the obturator internus muscle. When the pelvic floor muscles are in chronic spasm, the nerve becomes compressed. A vicious circle forms: pain triggers muscle spasm, the spasm increases pressure on the nerve, and the pressure intensifies the pain.

Not only women. Pudendal neuralgia is diagnosed more often in women (after childbirth and gynaecological operations), but it also affects men. Prof. Michael Hibner of the Arizona Center for Chronic Pelvic Pain, one of the most experienced surgeons operating on the pudendal nerve, in his chapter on pudendal neuralgia (open access) lists among the causes: cycling, prolonged sitting, constipation, anal intercourse and excessive masturbation. The mechanism in the latter case is chronic, repeated tensing of the pelvic floor muscles (especially the bulbospongiosus) and irritation of the dorsal nerve of the penis. In a conversation with me, Prof. Hibner confirmed that he sees such patients in his practice (personal communication, 2026).

How to distinguish pudendal nerve pain from testicular pain?

• the pain affects the skin of the scrotum, the perineum, the penis, the anal region – the testicle itself is not tender on examination
• character: burning, tingling, numbness, sometimes a sensation of a “foreign body” in the perineum
• it worsens when sitting, subsides when standing or lying down
• relief when sitting on a toilet seat (the weight rests on the ischial tuberosities, not on the perineum)
• often pain during or after ejaculation, sometimes numbness of the penis
• the pain usually does not wake you from sleep
• muscle tenderness on rectal examination

Treatment. The first step is removing the cause – less sitting, changing the saddle or giving up cycling, a break from the activity that triggers the pain. The second step is pelvic floor physiotherapy – Hibner calls it the gold standard and says in an interview that he himself would choose it before injections, medication and surgery. Then: muscle relaxants, drugs for neuropathic pain (gabapentin, pregabalin), image-guided pudendal nerve blocks, botulinum toxin into the pelvic floor muscles. Surgical decompression of the nerve is a last resort, for the few patients with confirmed permanent entrapment (scar, mesh).

10. Amiodarone – a drug used for cardiac arrhythmias

Amiodarone can cause sterile epididymitis in up to 11% of adult patients taking this drug. This is due to the very high concentration of the drug that can accumulate in the tissues of the testicle and epididymis. Importantly, the symptoms do not resolve on their own – discontinuing the drug may be necessary. That is why, in chronic scrotal pain, the doctor should ask about the medications you take. Not related to a previous vasectomy.

11. Interstitial cystitis (referred pain)

Chronic bladder pain syndrome can manifest as pain radiating to the scrotum. Characteristic is the coexistence of suprapubic pain related to bladder filling and urinary symptoms (frequent urination, urgency). Not related to a previous vasectomy.

12. Psychological factors

Psychological factors can play a significant role in chronic scrotal pain, especially when no organic cause can be identified. Factors that may influence the perception of chronic pain in the genital area include: anxiety disorders, depression, somatisation disorder (a tendency to experience mental stress as bodily symptoms), sexual dysfunction and chronic stress. This does not mean the pain is “made up” – on the contrary, psychological mechanisms can genuinely affect the perception of pain and the pain threshold. That is why, in difficult cases, it is worth considering a psychological consultation as part of comprehensive treatment.

How does the diagnostic process work?

Proper diagnostics is the key to effective treatment. The urologist will take a detailed history and perform a physical examination, and order additional tests if needed.

Detailed medical history

The doctor will ask you about:

• the location of the pain – where exactly does it hurt? Is the pain unilateral or bilateral?
• the character of the pain – is it sharp, dull, burning, stabbing?
• the duration – when did the pain start? Is it constant or paroxysmal?
• radiation – does the pain radiate to other areas of the body?
• intensity – how severe is the pain on a scale from 0 to 10?
• aggravating and relieving factors – what makes the pain worse (exertion, sitting, walking)? What brings relief?
• its relationship to urination, bowel movements and ejaculation
• the presence of swelling or a lump in the scrotum

Also important is information about:

• past illnesses (including sexually transmitted diseases)
• past procedures and operations (vasectomy, hernia surgery, orthopaedic operations)
• spinal problems – this is key information, because spinal nerve compression in the lower spine is the most common cause of pain referred to the scrotum
• mental health conditions (depression, anxiety)

Questions about the spine the doctor may ask:

• Do you have, or have you had, lower back pain?
• Do you work in a sitting position for many hours (e.g. as a driver)?
• Do you lift heavy objects?
• Does the pain worsen with certain body positions or movements?
• Do you feel numbness or tingling in your legs, groin or scrotum?
• Have you ever been diagnosed with discopathy or sciatica?

The answers to these questions help assess whether the cause of the scrotal pain may be spinal nerve compression – the most common and often the easiest to treat cause of referred pain.

Types of pain – nociceptive and neuropathic

Distinguishing the type of pain helps in choosing the right treatment:

Nociceptive pain (tissue pain) – described as dull, deep, “diffuse”. It intensifies with pressure on the testicle. It may be accompanied by enlargement or atrophy of the testicle. This is the typical pain resulting from tissue damage or irritation.

Neuropathic pain (nerve pain) – characterised by a burning sensation, hyperaesthesia (hypersensitivity) or hypoaesthesia, radiating to the skin of the scrotum. It can be triggered by walking, bending over or hip hyperextension. Relief often occurs when lying down and with the thigh flexed. This type of pain suggests nerve damage or dysfunction.

Allodynia – a particular phenomenon in which even a gentle touch, which normally should not hurt, causes pain. It indicates hypersensitivity of the nervous system.

Physical examination

• Inspection of the scrotum and groin area – the doctor looks for scars from previous procedures, swelling, asymmetry.
• Palpation – the testicle, epididymis, vas deferens and spermatic cord are examined in turn. The doctor assesses which structures are painful.
• Examination of the groins – looking for a hernia.
• Rectal examination – allows assessment of the prostate and of the tension and tenderness of the pelvic floor muscles. This is a very important part of the examination, as it can reveal muscle tension as the cause of the pain.

Additional tests

Hormone and vitamin tests. Studies have shown that a significant proportion (up to 76%) of patients with chronic scrotal pain have a deficiency of testosterone or vitamin B12. In some patients, supplementing these deficiencies brought pain relief. That is why the doctor may order blood tests for testosterone and vitamin B12 levels.

Urine test. It allows a urinary tract infection to be ruled out and detects blood in the urine, which may indicate stones or other conditions.

Scrotal ultrasound (ultrasonography). This is the basic imaging test for scrotal pain. It makes it possible to see the structures inside the scrotum and to detect abnormalities such as:

• testicular tumours
• epididymal cysts
• varicoceles
• hydroceles (fluid accumulation around the testicle)
• inflammatory changes
• signs of congestion (obstruction)

Computed tomography (CT) of the abdomen and pelvis. It may be needed when urinary stones, an abdominal tumour or other causes of referred pain are suspected.

Spinal imaging. Because spinal nerve compression in the lower spine is the most common cause of pain referred to the scrotum, spinal imaging can be a very important part of the diagnostic work-up. X-ray or magnetic resonance imaging (MRI) of the lumbosacral spine may be indicated if:

• the pain suggests a spinal origin (e.g. it worsens in certain positions)
• there is accompanying back pain or numbness of the limbs
• other causes of scrotal pain have been ruled out
• the patient has a history of spinal problems

It is worth remembering that even in the absence of clear back pain, the spine may be the source of the problem.

Spermatic cord block – an important diagnostic tool

One of the most important tools in the diagnosis of chronic scrotal pain is the spermatic cord block. It involves injecting a local anaesthetic (similar to the one used at the dentist) into the area of the spermatic cord.

How is the diagnostic block performed? The doctor isolates the spermatic cord near the pubic tubercle and injects about 20 ml of anaesthetic solution (e.g. bupivacaine) with a thin needle. The procedure is performed on an outpatient basis and takes a few minutes. The aim is to check whether the source of the pain is in the testicle and the cord.

What does the result mean?

• A positive response (pain reduction by more than 50%, lasting more than 4 hours) – suggests the pain originates from the nerves of the spermatic cord and the patient may benefit from surgical treatment.
• A negative response (no improvement or very short-lasting relief) – suggests the source of the pain is elsewhere or central sensitisation has occurred. In that case, surgical treatment will probably not bring the expected results.

The good news: the spermatic cord block is not only a diagnostic test but can also have a therapeutic effect. A series of several blocks can “break the pain cycle” and bring long-lasting relief in some patients.

How is chronic scrotal pain treated?

The treatment of chronic scrotal pain should be tailored individually to each patient, depending on the identified cause and the response to previous therapies. Cooperation between specialists from different fields is often necessary: a urologist, a pain specialist, a physiotherapist and sometimes a psychologist.

Conservative (non-surgical) treatment

Basic treatment. After ruling out serious causes (tumour, hernia, stones), you can start with simple methods:

• warm baths (sitz baths)
• wearing snug, scrotum-supporting underwear
• avoiding activities that aggravate the pain
• changes in diet and lifestyle:
  • eliminating caffeine, citrus fruits, hot spices and chocolate
  • avoiding constipation (it can aggravate the pain)
  • avoiding prolonged sitting
  • regular, moderate physical activity

Treating infections. If an infection is the cause, the doctor will prescribe an antibiotic. It is important, however, that repeated courses of antibiotics without a confirmed infection are unjustified and can delay proper treatment.

Pelvic floor physiotherapy. If the pain is related to pelvic floor muscle tension (bilateral symptoms, pain on ejaculation, muscle tenderness on rectal examination), a referral to a physiotherapist specialising in pelvic floor treatment can be very effective. The physiotherapist uses techniques such as muscle relaxation, biofeedback and exercises.

Anti-inflammatory drugs. Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, can reduce pain and inflammation. In some patients they may be sufficient as the only form of treatment.

Drugs used for neuropathic pain. In at least 30% of patients with chronic scrotal pain, a neuropathic component (related to abnormal nerve function) plays a significant role. In such cases the following drugs may be effective – all available only on prescription, used under medical supervision:

• Gabapentin – an anti-epileptic drug that modulates nerve conduction. In studies, over 60% of patients taking gabapentin reported a pain reduction of at least 50%.
• Amitriptyline – a drug from the tricyclic antidepressant group, used in low analgesic doses (10-20 mg at night). It works by affecting the neurotransmitters involved in pain conduction. Possible side effects include dizziness, dry mouth and drowsiness.
• Nortriptyline – similar to amitriptyline, it is also effective in some patients.
• Testosterone – when a low level has been confirmed.
• Tamsulosin – a drug used mainly for benign prostatic hyperplasia; there is some evidence it may help selected patients with chronic scrotal pain.

Additional non-surgical treatment methods

Dry needling of trigger points. A relatively new method involving puncturing painful trigger points in the muscles with a thin needle. In one study, as many as 85% of patients with chronic scrotal pain felt improvement after an average of 4-5 sessions.

Sacral nerve stimulation. In resistant cases of neuropathic pain, implantation of a sacral nerve stimulator is considered. The method is reserved for patients in whom other treatments have failed.

Cryoablation (freezing) of the cord nerves. A newer alternative method for patients in whom microsurgical denervation has failed. Nerves are sensitive to low temperatures – at -15 to -20°C they undergo complete denervation. Early results indicate effectiveness in about 74% of patients.

Botulinum toxin injections. Botulinum toxin can inhibit neurogenic inflammation and reduce chronic pain by blocking the release of neuropeptides. Early studies suggest significant relief in about 70% of patients.

A series of spermatic cord blocks. If a single diagnostic block brought relief, the doctor may propose a series of blocks (4-5 injections at 2-week intervals) using an anaesthetic and a steroid. This can “break the pain cycle” and bring long-lasting improvement, especially in patients whose pain has lasted less than 6 months.

Surgical treatment

Surgical treatment can bring significant and long-lasting improvement, but the key to success is proper patient selection. Surgery is not appropriate for everyone.

Treating specific structural abnormalities. If a specific anatomical cause has been identified, removing it can solve the problem:

• hydrocele removal (hydrocelectomy) – for hydrocele-related pain
• epididymal cyst removal (spermatocelectomy)
• varicocele surgery (varicocelectomy)
• hernia surgery

For these specific conditions, the effectiveness of surgery in relieving pain is 75-100%.

Removal of the epididymis (epididymectomy). If the pain is clearly located in the epididymis, its surgical removal can be considered. The effectiveness of this method is 75-90% in properly selected cases.

Microsurgical denervation of the spermatic cord (MDSC). This is currently the preferred surgical method for patients with chronic scrotal pain in whom:

• the pain is diffuse (not limited to the epididymis)
• no specific anatomical cause has been identified
• the spermatic cord block brought relief lasting more than 4 hours

What does the procedure involve? The operation is performed under general anaesthesia, on an outpatient basis (the patient returns home the same day). The surgeon makes a small (3-5 cm) incision in the groin, isolates the spermatic cord and, under an operating microscope, cuts all the nerves in the cord while preserving:

• the arteries (supplying blood to the testicle)
• the lymphatic vessels (preventing hydrocele formation)
• the vas deferens (if the patient cares about fertility and has not had a vasectomy)

What are the results? Complete resolution of pain after MDSC occurs in 50-100% of patients, and partial improvement in a further 3-24%. The risk of complications is low: hydrocele – below 1%, testicular atrophy – about 1%.

Restoring vas deferens patency (vasovasostomy) – vasectomy reversal. In patients with post-vasectomy pain syndrome, if the cause is obstruction (blockage of sperm outflow), one option is surgical reversal of the procedure. The effectiveness in reducing pain is 50-69%. The disadvantages of this method are the restoration of fertility (which is not always desired) and the fact that the procedure is expensive and usually not reimbursed.

Removal of the testicle (orchiectomy). This is a last-resort method, used only when all other options have failed. Orchiectomy is not effective in all patients – the failure rate is 30-80%! Removing the testicle also means reduced testosterone production and loss of fertility potential on that side. For these reasons, orchiectomy should be treated as a last resort.

Summary – the most important information

• Chronic scrotal pain is pain or discomfort within the scrotum (testicle, epididymis, spermatic cord) lasting at least 3 months and affecting daily functioning.
• The causes are diverse – from inflammation, through varicoceles and cysts, to pain referred from the spine, the prostate, the pelvic floor muscles or the abdominal cavity. In 35-45% of patients no clear cause can be established.
• Diagnostics includes a detailed history, a physical examination (including a rectal examination to assess the pelvic floor muscles), scrotal ultrasound and, if needed, other imaging tests.
• The spermatic cord block is an important diagnostic tool that helps predict which patients will benefit from surgical treatment.
• Conservative treatment includes anti-inflammatory drugs, drugs for neuropathic pain, pelvic floor physiotherapy and series of blocks.
• Surgical treatment (especially microsurgical denervation of the spermatic cord) can bring significant improvement in properly selected patients.
• A multidisciplinary approach involving a urologist, a pain specialist, a physiotherapist and a psychologist often gives the best results.

If you suffer from chronic scrotal pain, do not hesitate to seek help. Although it can be frustrating that diagnosis and treatment take time, there are many effective methods that can bring relief and significantly improve your quality of life.

Frequently asked questions about testicular pain (FAQ)

How long does scrotal pain have to last to be considered chronic?

Scrotal pain is considered chronic when it persists for at least 3 months and disrupts the patient’s daily functioning – meaning you cannot concentrate on everyday activities because it hurts all the time. Shorter pain that resolves on its own or after treatment is classified as acute.

Can chronic scrotal pain be a symptom of testicular cancer?

Testicular cancer more often presents as a painless lump than as pain. However, any chronic scrotal pain requires a diagnostic work-up, which includes an ultrasound examination to rule out cancer. Pain as the only symptom of a testicular tumour is rare, but it must always be ruled out.

Can testicular pain originate from the spine?

Yes, this is statistically the most common cause of pain referred to the scrotum. Compression of spinal nerves in the lumbar region (e.g. with discopathy or sciatica) can cause pain felt in the scrotum, groin and testicles – even without accompanying back pain. The nerves innervating the scrotum originate from levels L1-L2 and S2-S4 of the spine, so any problem in the lumbosacral spine can produce pain felt in the testicles.

Can a diseased prostate produce pain felt in the testicles?

Yes, up to 50% of cases of prostatitis can produce complaints felt in the testicles. This happens because the prostate and the testicles share innervation from the same spinal cord levels. The brain receives pain signals from the same nerve “junction” and mistakenly “projects” the pain onto the testicle, even though the testicle itself is healthy.

Can scrotal pain be caused by pudendal nerve compression?

Yes. Chronically tense pelvic floor muscles can compress the pudendal nerve, which innervates the skin of the scrotum, the perineum and the penis. The pain has a burning or tingling character, worsens when sitting, and the testicle itself is not tender. This also affects men – the causes listed include cycling, prolonged sitting, constipation and excessive masturbation. The basis of treatment is pelvic floor physiotherapy.

Can cycling cause testicular pain?

Yes, years of long training rides with a poorly chosen saddle can lead to ischaemia-related changes within the testicle. The mechanism involves chronic microtraumatisation – the constant pressure of the saddle on the perineum and blood vessels, vibrations and friction. In cyclists, epididymal calcifications, scrotal calculosis (“scrotal pearls”), hydroceles and epididymal cysts have been found. Such changes are often permanent and irreversible.

What is the difference between nociceptive and neuropathic pain?

Nociceptive (tissue) pain is dull, deep, “diffuse” and worsens with pressure on the testicle – the typical pain resulting from tissue damage. Neuropathic (nerve) pain is characterised by burning, hyper- or hyposensitivity, radiation to the skin of the scrotum, and can be triggered by walking or bending over. The distinction is important because each type requires different treatment.

What tests are performed for chronic scrotal pain?

The basic test is a scrotal ultrasound. In addition, the doctor may order a urine test, a semen culture, testosterone and vitamin B12 levels (a deficiency has been found in up to 76% of patients with chronic scrotal pain), and if referred pain is suspected – imaging of the spine (X-ray, MRI) or the abdominal cavity.

Can stress and the psyche affect scrotal pain?

Yes, psychological factors can play a significant role in chronic scrotal pain, especially when no organic cause can be identified. Anxiety disorders, depression, chronic stress and somatisation disorder can affect pain perception and lower the pain threshold. This does not mean the pain is “made up” – in difficult cases, a psychological consultation can be a valuable part of comprehensive treatment.

Can a heart medication (amiodarone) cause testicular pain?

Yes, amiodarone (a drug used for cardiac arrhythmias) can cause sterile epididymitis in up to 11% of patients taking this drug. This is due to the very high concentration of the drug accumulating in the tissues of the testicle and epididymis. Importantly, the symptoms do not resolve on their own – discontinuing the drug may be necessary.

What medications help with chronic scrotal pain?

Treatment includes non-steroidal anti-inflammatory drugs (ibuprofen, naproxen) and, when there is a neuropathic component, gabapentin or tricyclic antidepressants (amitriptyline) in low analgesic doses. In selected patients, tamsulosin may help, and in cases of deficiency – supplementation of testosterone or vitamin B12. All these drugs require a prescription and should be used under medical supervision.

What is a spermatic cord block?

A spermatic cord block is an injection of an anaesthetic (about 20 ml of bupivacaine) into the area of the spermatic cord at the pubic tubercle. It serves both as a diagnostic test (a positive response is a pain reduction of more than 50% for more than 4 hours) and as a treatment method. A series of 4-5 blocks at 2-week intervals can “break the pain cycle” and bring long-lasting relief.

What new treatment methods for scrotal pain are available?

Newer methods include: dry needling of trigger points (effective in 85% of patients after 4-5 sessions), botulinum toxin injections (relief in about 70% of patients), cryoablation of the cord nerves (freezing at -15 to -20°C, effective in 74% of patients) and sacral nerve stimulation in resistant cases.

When is surgery necessary for scrotal pain?

Surgery is considered when conservative treatment brings no results and the spermatic cord block provides relief lasting more than 4 hours. For specific anatomical changes (varicoceles, cysts, hydroceles, hernias), the effectiveness of surgery reaches 75-100%. For diffuse pain, the most effective method is microsurgical denervation of the spermatic cord (MDSC), with complete resolution of pain in 50-100% of properly selected patients.

Does removing the testicle cure chronic pain?

Removal of the testicle (orchiectomy) is a last-resort method and not always effective – the failure rate is 30-80%. This means the pain may persist even after the testicle has been removed, due to central sensitisation of the nervous system. That is why orchiectomy should only be considered when all other methods have failed.

Which doctor should I see about testicular pain?

The first step should be a visit to a urologist, who will perform a physical examination (including a rectal examination to assess the prostate and pelvic floor muscles) and order a scrotal ultrasound. Depending on the suspected cause, a consultation with a pelvic floor physiotherapist, a neurologist or an orthopaedist may be needed (if pain of spinal origin is suspected), and in difficult cases – with a pain specialist or a psychologist.

Note: this material is for information and education. It does not replace a medical consultation. If you have complaints after a vasectomy, contact the doctor who performed the procedure or a urologist.

Prepared by: Robert Kulik, andrologist performing vasectomies since 2013.

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