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Chronic Scrotal Content Pain

Chronic scrotal content pain (CSCP), also called chronic orchialgia or chronic testicular pain, is intermittent or constant pain perceived in the testis, epididymis or spermatic cord for 3 months or longer that interferes with daily activity enough to prompt medical attention.[1][5][6] AUA 2025 describes the typical patient as presenting with pain in the testes and tenderness of the epididymis, spermatic cord or both, and notes that specific CSCP data are limited and that most management options are off-label.[2] EAU uses the term primary scrotal pain syndrome for persistent or recurrent episodic pain localized within the scrotal contents, without proven infection or other obvious local pathology, and names post-vasectomy and post-inguinal hernia repair pain as two special forms.[4]

Evaluation aims to exclude a treatable scrotal or referred cause, to separate CSCP from chronic prostatitis or chronic pelvic pain syndrome (CP/CPPS), and to identify the men in whom a neuroablative or extirpative operation is reasonable. For the wider male pelvic pain framework, see Chronic Pelvic Pain; the operative detail for the principal surgical option is on Microdenervation of the Spermatic Cord.

Terminology and Phenotype​

AUA 2025 separates CSCP from CP/CPPS by distribution. Perineal, bilateral scrotal, penile or suprapubic pain, dysuria or ejaculatory pain supports CP/CPPS; isolated unilateral chronic scrotal pain without other pelvic pain or urinary symptoms supports CSCP (Statements 10–11; Expert Opinion).[1] The two conditions overlap. In one cord-denervation series, pelvic floor muscle spasm was present in 19 of 103 men and independently predicted surgical failure (see Conservative care).[18]

The older definition of chronic orchialgia (Davis 1990) is intermittent or constant unilateral or bilateral testicular pain of 3 months or longer that significantly interferes with the patient's daily activities.[5] The 3-month threshold matches the ICD-11 chronic pelvic pain definition adopted by EAU.[4]

Epidemiology​

Population prevalence data for CSCP are sparse.[6][13] The best-quantified subgroups are iatrogenic:

  • After vasectomy. A 2020 meta-analysis of 18 studies reported post-vasectomy pain in 15% (95% CI 9–25%) of men, 24% after scalpel and 7% after no-scalpel technique, and post-vasectomy pain syndrome (PVPS) in 5% (95% CI 3–8%), with similar estimates for both techniques.[7] The 2012 AUA vasectomy guideline counseled that chronic scrotal pain with a negative effect on quality of life occurs in about 1–2% of men.[8]
  • After inguinal hernia repair. HerniaSurge reports clinically significant chronic postoperative inguinal pain in the 10–12% range, decreasing over time, and debilitating pain affecting daily activities or work in 0.5–6%. These figures describe groin pain in general; the scrotal-referred fraction is not separately reported.[9]

Men undergoing cord denervation have long symptom histories: in the Strom and Levine series, mean age was 40.3 years and mean pain duration 62 months.[22]

Neuroanatomy​

Somatic sensation from the scrotal contents travels in the ilioinguinal nerve and the genital branch of the genitofemoral nerve; the pudendal nerve supplies the posterior scrotum. Disease or surgery anywhere along these nerves can produce pain perceived in the scrotum.[4] The genital branch enters the deep ring and runs within the cord; the ilioinguinal nerve runs alongside the cord in the inguinal canal, outside its internal contents. Autonomic fibers accompany the testicular vessels and the vas.[11][12] For gross anatomy see The Testicles & Scrotum and Pelvic Neuroanatomy.

Two histologic studies define the surgical target:

  • Nerve distribution. In 11 spermatic cords and 36 spermatic fascia biopsies, PGP 9.5 staining showed dense innervation, with about 50% of nerves near the vas deferens and 20% in the spermatic fascia. Sensory and sympathetic fibers were co-localized within the same nerves; parasympathetic fibers were few.[11]
  • Wallerian degeneration. In cord biopsies from 57 denervation procedures, a median of 25 small-diameter (<1 mm) nerve fibers was identified. Wallerian degeneration was present in 48 of 57 (84%) orchialgia specimens and 2 of 10 (20%) controls, concentrated in the cremasteric muscle layer, the perivasal tissues and the posterior periarterial lipomatous tissue (the "trifecta nerve complex").[10]

Shared T10–L1 segmental innervation with the kidney and ureter, and S2–S4 pudendal input to the posterior scrotum, explain why referred pain from the upper tract, the pelvic floor or the spine can present as testicular pain.[6][12]

Etiology​

CategoryExamplesNotes
IdiopathicNo structural, infectious or referred cause after full evaluationA large share of surgical series; the group in which denervation has been most studied[6][22]
Post-vasectomy pain syndromeCongestive epididymal pain, sperm granuloma, perivasal neuropathyPVPS in about 5% of men after vasectomy[7]
Post-herniorrhaphy and inguinal neuropathyIlioinguinal, iliohypogastric or genital-branch entrapment; mesh-related cord fibrosisEAU treats post-hernia repair scrotal pain as a distinct form[4][9]
VaricoceleDull, dragging pain worse with standing or exertionPain character predicts the response to repair[28]
Epididymal diseaseChronic epididymitis, epididymal cyst, post-vasectomy epididymal congestionPalpable focal abnormality predicts response to epididymectomy[26]
Other scrotal surgeryHydrocelectomy, spermatocelectomy, varicocelectomyCord denervation remains an option after failed prior ipsilateral surgery[34]
Referred painUreteral calculus, lumbar radiculopathy, pudendal neuralgiaSee pudendal neuralgia[6][12]
Pelvic floor myofascial painLevator and obturator trigger points referring to the scrotumIndependently predicts failure of cord denervation[17][18]

Tumor, torsion, acute epididymo-orchitis, hernia and abscess are acute or structural causes of scrotal pain and fall outside the CSCP definition; the evaluation exists in part to exclude them.[12][13]

Evaluation​

The AUA evaluation statements apply to all men with chronic pelvic pain, with CSCP-specific additions.[1][3]

  1. History. Onset, laterality, character (dull, dragging, sharp, burning), radiation to groin, perineum or flank, and triggers (standing, exertion, ejaculation, sitting). Record prior vasectomy, hernia repair, scrotal or inguinal surgery, trauma, infection and back pain. Validated symptom and quality-of-life questionnaires may be used (Statement 2; Clinical Principle); see Assessment Tools & Questionnaires.[1]
  2. Examination. Examine the testes, epididymides and cords standing and supine, with Valsalva for varicocele and hernia; map tenderness to the testis, epididymis, cord or external ring. Examine the prostate and palpate the pelvic floor transrectally (Statement 5; Expert Opinion), and screen the pelvis, hips and lower spine for neurological and musculoskeletal abnormalities (Statement 4; Expert Opinion).[1] See Male Urogenital Exam.
  3. Urinalysis and urine culture, with sexually transmitted infection testing when the history suggests it.[1]
  4. Scrotal ultrasound may be performed (Statement 6; Clinical Principle).[1] It documents varicocele, hydrocele, spermatocele and epididymal change before surgery. In one epididymectomy series, men with an ultrasound abnormality but no palpable lesion had a lower satisfactory outcome (67%) than men with a palpable painful abnormality (87.5% cured).[26] See Ultrasound.
  5. Exclude referred causes. Cross-sectional imaging of the upper tract when flank pain, hematuria or stone history suggests ureteral obstruction; spine imaging when radicular features are present; pudendal assessment when posterior scrotal or perineal pain dominates.[6][12]
  6. Psychosocial screening. Depression, anxiety, catastrophizing and sleep disturbance amplify chronic pain and affect surgical counseling; the biopsychosocial model in Chronic Pelvic Pain applies.[12][13]

Spermatic cord block​

In isolated unilateral CSCP, AUA permits a diagnostic spermatic cord block, ilioinguinal block or both (Statement 12; Expert Opinion).[1] The block localizes the pain generator to the cord and is the main selection test for denervation. Technique and dosing are on Nerve Blocks.

  • Prognostic value. In 74 men (77 testicular units) treated with denervation, the degree of temporary relief after cord block predicted sustained improvement (p = 0.05), and a positive block was an independent predictor of response (p = 0.03).[14]
  • Placebo-controlled screening. Oomen and colleagues gave 180 men double-blind cord blocks with lidocaine, bupivacaine or saline on three occasions. The response was positive in 37% and negative in 51%; only men with a positive response were offered denervation.[15]
  • Limits. Relief can inform counseling but does not guarantee surgical success or exclude a second pain generator such as the pelvic floor.[1][18]

Management​

AUA endorses multimodal care that usually starts nonsurgically, with reassessment and discontinuation of ineffective treatment.[1] The ladder below lists options by escalating invasiveness; it is not a mandatory sequence, and the etiology often points directly to a specific operation.

TierOptionIndication and selectionEvidence and guideline position
ConservativeNSAIDs and analgesicsFirst-line for most menCSCP-specific data are limited to reviews; see NSAIDs[12][13]
ConservativeSingle antimicrobial trialAntibiotic-naive CSCP onlyOne 10-day course (Statement 33; Clinical Principle); avoid repeated courses with negative cultures, negative STI tests or after vasectomy (Statement 42; Clinical Principle)[2][3]
ConservativeNeuropathic agentsBurning or lancinating pain; idiopathic CSCPGabapentin 61.5% and nortriptyline 66.6% achieved more than 50% improvement in a 26-patient pain-clinic series; no man with PVPS reached that threshold[16]; see Gabapentinoids and TCAs
ConservativePelvic floor physical therapyPelvic floor tenderness or tightness on rectal examAUA Statement 36 (Expert Opinion)[2]; 30 men had a median 4.5/10 fall in pain, and analgesic use fell from 73.3% to 44.0%[17]; see Pelvic Floor Physical Therapy
ConservativeCognitive and behavioral therapyCatastrophizing, mood disorder, central sensitizationAdjunct within multimodal care[12][13]
ProceduralSpermatic cord block (therapeutic series)Positive diagnostic blockDiagnostic use is AUA Statement 12 (Expert Opinion)[1]; a review cites 36–80% success for cord blocks[30]
ProceduralPulsed radiofrequencyIlioinguinal or genital-branch neuropathy, often after surgeryA 2022 review found six reports, including one sham-controlled randomized trial in post-surgical orchialgia, and no device-related adverse effects[19]
ProceduralBotulinum toxin cord blockNot established72% reported pain reduction at 1 month in an open-label pilot (n = 18)[20]; the randomized trial (n = 64) found no benefit over local anesthetic alone[21]; see Scrotal BoNT/A
ProceduralNeuromodulationRefractory to all other optionsPain-specialist discussion, including neuromodulation (Statement 38; Expert Opinion)[2]; see Sacral Neuromodulation
SurgicalMicrodenervation of the spermatic cordCord-localized pain, especially after a positive cord blockConditional Recommendation, Grade C (Statement 34)[2]; EAU weak recommendation when testicular pain improves after cord block[4]; see MDSC
SurgicalVasectomy reversalPVPSStatement 35 (Expert Opinion)[2]
SurgicalEpididymectomyPain and tenderness focal to the epididymis after failed conservative careStatement 39 (Expert Opinion)[2]
SurgicalInguinal triple neurectomyPost-herniorrhaphy neuropathic painHerniaSurge: selected cases after failed pharmacologic and interventional treatment[9][27]
SurgicalVaricocelectomyPainful varicocele concordant with symptomsMicrosurgical subinguinal repair favored for pain[28]
SurgicalInguinal orchiectomy with entire cordMost invasive option, after other treatment failsStatement 40 (Expert Opinion), inguinal rather than scrotal route[2]

Conservative care​

Most men start with anti-inflammatory analgesia, a neuropathic agent when the pain has neuropathic features, and pelvic floor physical therapy when the examination finds pelvic floor tenderness.[2][12][16][17] In the Sinclair series, gabapentin and nortriptyline helped idiopathic orchialgia, but no man with post-vasectomy pain reached 50% improvement.[16] Pelvic floor findings matter beyond physical therapy: in the Cleveland Clinic series, pelvic floor muscle spasm was the only independent predictor of failure of cord denervation (OR 3.95, p = 0.02), with failure in 47% of men with spasm and 23% without.[18] For examination and protocols, see Myofascial Pelvic Pain.

Procedures​

Cord blocks serve diagnosis first. Pulsed radiofrequency to the ilioinguinal nerve and genital branch is an option in post-surgical orchialgia, with evidence limited to small series and one sham-controlled trial with short follow-up.[19] Botulinum toxin added to a cord block did not outperform local anesthetic alone in the randomized trial, and AUA 2025's ungraded discussion reaches the same conclusion.[3][21]

Surgery​

Surgery is reserved for men with persistent, function-limiting pain after conservative care, with the choice set by the pain generator.[2][12]

  • Microdenervation of the spermatic cord (MDSC) divides the nerve-bearing tissues of the cord while preserving the testicular arteries, lymphatics and usually the vas. It preserves the testis and has the largest outcome literature for idiopathic CSCP and PVPS. Single-center series report complete relief in 71% of testicular units (95 units, mean follow-up 20.3 months) and a 71% success rate in PVPS (28 units).[22][32] Technique, selection and outcomes are on Microdenervation of the Spermatic Cord.
  • Vasectomy reversal addresses PVPS with a presumed congestive or obstructive mechanism. In a 20-year single-institution review (123 procedures, 31 respondents), 34% had complete resolution and mean pain fell from 6.4 to 2.7.[23] A systematic review of five studies (123 patients) reported pain-score reductions of 60–83%, all from case series.[24] Reversal also restores fertility, which some men do not want.
  • Epididymectomy suits pain and tenderness localized to the epididymis. In 225 men treated over 20 years, 72% reported cure or improvement.[25] Selection drives the result: 87.5% of men with a palpable painful epididymal abnormality were cured, compared with 20% cured and a further 33% improved when both examination and ultrasound were normal.[26] Dissection stays close to the epididymis to protect testicular perfusion.[2]
  • Inguinal triple neurectomy (ilioinguinal, iliohypogastric and genital branch, with proximal-end implantation and without mobilizing the cord) was described by Amid for refractory post-herniorrhaphy neuropathic pain, in 49 patients treated from 1995 to 2001.[27] HerniaSurge recommends combined pharmacologic and interventional management first, then, in selected cases, triple neurectomy and, in selected cases, mesh removal.[9] Cord denervation after hernia repair has been reported with complete resolution in 43% (20 of 47 cords) and improvement in 87% at a median 7 weeks.[33]
  • Varicocelectomy is used when the varicocele is concordant with the pain. In a 14-study meta-analysis, dull pain resolved more often than dragging pain (OR 5.73) or sharp pain (OR 8.72), resolution did not differ by varicocele grade, and subinguinal and microsurgical repairs outperformed high ligation and laparoscopic repair.[28]
  • Inguinal orchiectomy with removal of the entire cord is the most invasive option; AUA specifies the inguinal rather than the scrotal route (Statement 40; Expert Opinion).[2] In Davis 1990, pain resolved in 11 of 15 (73%) after inguinal orchiectomy and 5 of 9 (55%) after scrotal orchiectomy.[5] Reviews cite success rates of 20–75% and 55–75%, so a substantial minority keep their pain after losing the testis, and cord denervation is generally offered before orchiectomy in idiopathic pain.[29][30][31]

Outcomes and Counseling​

Surgical counseling covers four points. The evidence base for every CSCP operation is retrospective and uncontrolled. A positive cord block improves the odds of success after denervation but does not guarantee it. Pelvic floor muscle spasm is associated with failure of cord denervation. Orchiectomy does not reliably cure pain.[1][2][14][18][29] After failed denervation, a second pain generator is sought before further surgery; in the Cleveland Clinic series, two men whose denervation failed improved after genitofemoral nerve block.[18]

See Also​

References​

1. Lai HH, Pontari MA, Argoff CE, et al. "Male Chronic Pelvic Pain: AUA Guideline: Part I Evaluation and Management Approach." J Urol. 2025;214(2):116-126. doi:10.1097/JU.0000000000004564

2. Lai HH, Pontari MA, Argoff CE, et al. "Male Chronic Pelvic Pain: AUA Guideline: Part III Treatment of Chronic Scrotal Content Pain." J Urol. 2025;214(2):138-146. doi:10.1097/JU.0000000000004566

3. American Urological Association. Diagnosis and Management of Male Chronic Pelvic Pain (Chronic Prostatitis/Chronic Pelvic Pain Syndrome and Chronic Scrotal Content Pain): AUA Guideline (2025). Approved March 2025. Full 2025 guideline

4. Engeler D, Baranowski AP, Berghmans B, et al. EAU Guidelines on Chronic Pelvic Pain. European Association of Urology; limited update March 2026. Guideline. Scrotal pain syndrome sections.

5. Davis BE, Noble MJ, Weigel JW, Foret JD, Mebust WK. "Analysis and management of chronic testicular pain." J Urol. 1990;143(5):936-939. doi:10.1016/s0022-5347(17)40143-1

6. Levine LA. "Chronic orchialgia: evaluation and discussion of treatment options." Ther Adv Urol. 2010;2:209-214. doi:10.1177/1756287210390409

7. Auyeung AB, Almejally A, Alsaggar F, Doyle F. "Incidence of post-vasectomy pain: systematic review and meta-analysis." Int J Environ Res Public Health. 2020;17(5):1788. PMC7084350

8. Sharlip ID, Belker AM, Honig S, et al. "Vasectomy: AUA guideline." J Urol. 2012;188(6 Suppl):2482-2491. doi:10.1016/j.juro.2012.09.080

9. HerniaSurge Group. "International guidelines for groin hernia management." Hernia. 2018;22(1):1-165. doi:10.1007/s10029-017-1668-x

10. Parekattil SJ, Gudeloglu A, Brahmbhatt JV, et al. "Trifecta nerve complex: potential anatomical basis for microsurgical denervation of the spermatic cord for chronic orchialgia." J Urol. 2013;190(1):265-270. doi:10.1016/j.juro.2013.01.045

11. Oka S, Shiraishi K, Matsuyama H. "Microsurgical anatomy of the spermatic cord and spermatic fascia: distribution of lymphatics, and sensory and autonomic nerves." J Urol. 2016;195(6):1841-1847. doi:10.1016/j.juro.2015.11.041

12. Levine LA, Hoeh MP. "Evaluation and management of chronic scrotal content pain." Curr Urol Rep. 2015;16:36. doi:10.1007/s11934-015-0510-1

13. Oh PJ, Bajic P, Lundy SD, Ziegelmann M, Levine LA. "Chronic scrotal content pain: a review of the literature and management schemes." Curr Urol Rep. 2021;22(2):12. doi:10.1007/s11934-020-01026-6

14. Benson JS, Abern MR, Larsen S, Levine LA. "Does a positive response to spermatic cord block predict response to microdenervation of the spermatic cord for chronic scrotal content pain?" J Sex Med. 2013;10(3):876-882. doi:10.1111/j.1743-6109.2012.02937.x

15. Oomen RJ, Witjens AC, van Wijck AJ, Grobbee DE, Lock TM. "Prospective double-blind preoperative pain clinic screening before microsurgical denervation of the spermatic cord in patients with testicular pain syndrome." Pain. 2014;155(9):1720-1726. PMID 24861586

16. Sinclair AM, Miller B, Lee LK. "Chronic orchialgia: consider gabapentin or nortriptyline before considering surgery." Int J Urol. 2007;14(7):622-625. doi:10.1111/j.1442-2042.2007.01745.x

17. Farrell MR, Dugan SA, Levine LA. "Physical therapy for chronic scrotal content pain with associated pelvic floor pain on digital rectal exam." Can J Urol. 2016;23(6):8546-8550. PMID 27995849

18. Murthy PB, Parekh NV, Vij SC, Shoskes DA. "Microscopic spermatic cord denervation for chronic orchialgia/chronic scrotal content pain: operative outcomes and predictors of failure." Transl Androl Urol. 2020;9(5):1931-1936. PMID 33209657

19. Alzahrani MA, Safar O, Almurayyi M, et al. "Pulsed radiofrequency ablation for orchialgia: a literature review." Diagnostics (Basel). 2022;12(12):2965. doi:10.3390/diagnostics12122965

20. Khambati A, Lau S, Gordon A, Jarvi KA. "OnabotulinumtoxinA (Botox) nerve blocks provide durable pain relief for men with chronic scrotal pain: a pilot open-label trial." J Sex Med. 2014;11(12):3072-3077. doi:10.1111/jsm.12707

21. Dockray J, Aljumaily A, Lau S, Jarvi KA. "A randomized, double-blind, controlled trial shows that onabotulinumtoxinA nerve blocks do not provide improved pain control in men with chronic scrotal pain." J Urol. 2020;203(4):767-772. PMID 31738115

22. Strom KH, Levine LA. "Microsurgical denervation of the spermatic cord for chronic orchialgia: long-term results from a single center." J Urol. 2008;180(3):949-953. doi:10.1016/j.juro.2008.05.018

23. Polackwich AS, Tadros NN, Ostrowski KA, et al. "Vasectomy reversal for postvasectomy pain syndrome: a study and literature review." Urology. 2015;86(2):269-272. PMID 26165616

24. Lahiji R, Safdar B, Abdollahzadeh A, et al. "Vasectomy reversal provides symptomatic relief in patients with postvasectomy pain syndrome: a systematic review." Urol Pract. 2026;13(2):166-171. doi:10.1097/UPJ.0000000000000909

25. Cole RM, Andino JJ, Daignault-Newton S, Quallich SA, Hadj-Moussa M. "Epididymectomy is an effective treatment for chronic epididymal pain." Urol Pract. 2024;11(2):409-415. doi:10.1097/UPJ.0000000000000515

26. Calleary JG, Masood J, Hill JT. "Chronic epididymitis: is epididymectomy a valid surgical treatment?" Int J Androl. 2009;32(5):468-472. doi:10.1111/j.1365-2605.2008.00880.x

27. Amid PK. "A 1-stage surgical treatment for postherniorrhaphy neuropathic pain: triple neurectomy and proximal end implantation without mobilization of the cord." Arch Surg. 2002;137(1):100-104. doi:10.1001/archsurg.137.1.100

28. Park JH, Pak K, Park NC, Park HJ. "How can we predict a successful outcome after varicocelectomy in painful varicocele patients? An updated meta-analysis." World J Mens Health. 2021;39:645-653. doi:10.5534/wjmh.190112

29. Lowe G. "Extirpative surgery for chronic orchialgia: is there a role?" Transl Androl Urol. 2017;6(Suppl 1):S2-S5. PMID 28725610

30. Malaguti SA, Lund L. "Gold standard care of chronic scrotal pain." Res Rep Urol. 2021;13:283-288. doi:10.2147/RRU.S278803

31. Parekattil SJ, Ergun O, Gudeloglu A. "Management of chronic orchialgia: challenges and solutions. The current standard of care." Res Rep Urol. 2020;12:199-210. doi:10.2147/RRU.S198785

32. Tan WP, Tsambarlis PN, Levine LA. "Microdenervation of the spermatic cord for post-vasectomy pain syndrome." BJU Int. 2018;121(4):667-673. doi:10.1111/bju.14125

33. Romanelli ME, Naelitz BD, Bole R, et al. "Microscopic spermatic cord denervation for chronic scrotal content pain following inguinal hernia repair: outcomes and predictors of success." Urology. 2026. PMID 41275976

34. Larsen SM, Benson JS, Levine LA. "Microdenervation of the spermatic cord for chronic scrotal content pain: single institution review analyzing success rate after prior attempts at surgical correction." J Urol. 2013;189(2):554-558. doi:10.1016/j.juro.2012.09.026