This paper presents a series of men with chronic idiopathic scrotal pain who had improvement in scrotal pain to an acceptable level with therapies treating IC/BPS (Table 3). Chronic idiopathic scrotal pain may be one of the variable presenting symptoms of a male with IC/BPS. IC/BPS is a progressive disorder that classically presents with urinary frequency, urgency, and bladder pain in any combination [9]. However, patients with IC/BPS often present initially with only a single symptom. This disease has an insidious development over many years from mild, intermittent symptoms to more classic and potentially more severe IC/BPS. As the disease develops in patients, they are assigned diagnoses based on their presenting symptoms, their sex, and with which specialty they are consulting. With time there is a progression of symptoms making the IC/BPS diagnosis more likely to be considered and confirmed. The challenge for clinicians is to diagnose IC/BPS early and initiate treatment before there is progression of symptoms and potential further damage to the bladder.
Characteristic, Median (IQR) |
Pentosan Polysulfate Sodium
(n=8) |
Bladder Instillation with Alkalinized Lidocaine and Heparin
(n=8) |
pvalue* |
Age (yr) |
43 (37-47)
|
45 (28-74) |
p=0.6
|
Duration of scrotal pain (yr) |
1 (0.7-1.6)
|
0.6 (0.6-1) |
p=0.7
|
Time to acceptable pain relief |
11 (6-12) months
|
60 (30-60) minutes |
|
Improvement in pain (%) |
50 (50-75)
|
74 (47-95)
|
p=0.5
|
Table 3: Summary of treatment of idiopathic orchialgia with standard therapy for IC/BPS.
IQR=Interquartile Range
*2-Sample t-test
Women with IC/BPS often present with suprapubic, bladder pain. However, multiple pain sites including the external genitalia are common [10]. Women with IC/BPS present with genital pain of either vulvodynia or dyspareunia [11,12]. Women with IC/BPS who have vulvodynia complain of pain, burning, irritation, or rawness in the vulvar area but on examination no identifiable source for the discomfort is identified. This vulvodynia appears to be referred pain from the bladder. If women with IC/BPS have external genital discomfort, it follows that men with IC/BPS would also present with external genital discomfort.
More male patients are now being diagnosed with IC/BPS [13,14]. Scrotal or testicular pain, not related to bladder fullness, was recognized as a predominant symptom. Back, perineal, or scrotal pain was the initial symptom in 7% of male IC/BPS patients and progressed to be a predominant symptom in 45% of patients [14]. There was a delay in diagnosis of IC/BPS in men between 2.5 to 4 years due to initial unsuccessful treatment for benign prostatic hypertrophy and chronic prostatitis. Men with perineal pain attributed to the prostate, now called chronic pelvic pain syndrome, may actually have IC/BPS with the perineal pain being referred from the bladder [15-17].
Patients with IC/BPS treated with PPS have shown a greater reduction in pain compared to placebo [18]. The benefit of treatment with PPS is that it is taken as an oral medication and can have long term responses. However, it may take several months for patients to improve.
Intravesical therapeutic solutions of alkalinized lidocaine and heparin have provided immediate relief of pain and urgency in patients with IC/BPS [5,6]. Henry et al. [19], demonstrated that patients with IC/BPS experienced a significant pain reduction durable for 2 days with alkalinized intravesical lidocaine. Intravesical instillations of heparin attained clinical remission in over 50% of patients with IC/BPS [20]. Combination of intravesical alkalinized lidocaine and heparin successfully attained immediate and sustained relief of pain in patients with IC/BPS refractory to conventional therapy [21]. The benefits of treatment with intravesical instillations of alkalinized lidocaine and heparin are rapid relief of symptoms and obtaining a presumed diagnosis of IC/BPS. However, the procedure does require catheterization.
Chronic idiopathic scrotal pain is a challenging and frustrating urological condition for both the patient and the clinician. Many men with this condition undergo multiple therapies and surgeries with no improvement in their symptoms [2]. Significant voiding symptoms were recognized in these males with chronic orchialgia. Based on our experience with women with IC/BPS presenting with vulvodynia, we extrapolated this clinical presentation of external genital pain to males with chronic idiopathic scrotal pain. Focused questioning and/or a voiding diary may elicit abnormal urinary symptoms supportive of the diagnosis of IC/BPS. Patients with chronic idiopathic scrotal pain, especially if they have significant voiding symptoms, are candidates for a diagnostic and therapeutic trial with intravesical instillations of alkalinized lidocaine and heparin.
Chronic idiopathic scrotal pain may be a presenting symptom of IC/BPS. External genitalia pain may be referred pain from the bladder in patients with IC/BPS. PPS therapy may offer relief of scrotal pain for males with IC/BPS. Intravesical instillations of alkalinized lidocaine and heparin can be both a diagnostic tool and therapeutic option for scrotal pain in males with IC/BPS.