A. Lee Dellon, Plastic Surgery, Johns Hopkins University, Towson, MD
Orchiectomy is done for tumor, infection, torsion, and trauma. When testicular pain persists after orchiectomy, or after other peritesticular procedures such as vasectomy or epididymectomy, the differential diagnosis must include neuroma of the genitofemoral nerve. Nine patients are presented with persistent pain after orchiectomy who were successfully treated by resecting the genitofemoral nerve, placing the proximal end below the pelvic brim. Eight of these patients would have had conservation of their testis if a neural origin had been considered prior to orchiectomy.
From July of 2009 through June of 2013, using our office computer database, nine patients were identified who had an orchiectomy but had persistent testicular pain. One man had a seminoma, but the other 8 had orchiectomy as the primary approach to treating testicular pain after vasectomy (3 men) or herniorraphy (5 men). Patient mean age was 44.3 years (range 25 to 78 years). Mean duration of pain from the index surgical procedure was 25.5 months (range 16 to 48 months). Diagnosis was demonstrated by physical examination with the trigger point being at the external inguinal ring duplicating the pain. Surgical approach exposed the external ring, retracted the spermatic cord or its remnant medially, and identified the 1 to 1.5 mm genitofemoral nerve posterior and lateral to where the spermatic cord was or would have been. The proximal end of the genitofemoral nerve was resected so that it dropped into the pelvis. Surgery was on the left side in 6 and right side in 3 men. The surgical technique will be demonstrated with intra-operative photographs. There were no post-operative complications.
Outcome data is available on 6 patients with a mean follow-up of 20.1 months (range 12 to 36 months). Three patients are less than 6 months, but are included for demographic purposes. Five of the six men had excellent relief and one good relief of their pain in the long-term group. To date, all 3 of the short-term group have excellent pain relief.
Testicular pain is transmitted via the genitofemoral nerve. Once intrinsic, organic testicular disease has been treated, persistent testicular pain should be considered as due to the genitofemoral nerve, which can be resected with high expectation of long-term pain relief. Eight of the nine patients reported here would have been sparred orchiectomy if a neural origin had been considered in the differential diagnosis.