Archives of Urology Category: Clinical Type: Research Article
Chronic Scrotal Pain: A Variable Symptom of Interstitial Cystitis/Bladder Pain Syndrome
- Philip C Bosch1*, Lowell Parsons C1
- 1 Department Of Surgery And Urology, UC San Diego Medical Center, San Diego, United States
*Corresponding Author:Philip C Bosch
Department Of Surgery And Urology, UC San Diego Medical Center, San Diego, United States
Tel:+1 8586577876, 7607433135,
Received Date: Apr 12, 2018 Accepted Date: Jun 06, 2018 Published Date: Jun 20, 2018
Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) is a chronic, slowly progressive syndrome characterized by variable degrees of urinary urgency, frequency, and bladder pain. However, IC/BPS presents in a variety of ways. Many patients develop insidiously progressive urinary frequency that does not bother the patient until it begins to interfere with their lifestyle. Patients progress to chronic pain cycles that can occur anywhere in the pelvis, including the bladder, urethra, penis, scrotum, vulva, or labia.
In this article we report our experience with sixteen males with chronic idiopathic scrotal content pain who had acceptable relief of their pain when treated with standard therapy for IC/BPS.
PATIENTS AND METHODS
PPS is the only oral FDA approved medication for the treatment of IC/BPS. PPS is felt to restore the bladder epithelial barrier integrity. The advantage of PPS is that it is taken as an oral medication. However, it may require several months of therapy before patients experience relief of IC/BPS pain symptoms . The dose of PPS used was 100 mg, two capsules given three times daily one hour before meals or two hours after meals.
Intravesical therapeutic instillations of alkalinized lidocaine and heparin are currently being utilized more frequently for the treatment of IC/BPS. Bladder instillations including heparin and alkalinized lidocaine offer the advantage of immediate relief of pain symptoms [5,6]. Intravesical instillations of alkalinized lidocaine and heparin have provided resolution of external genital pain in women with IC/BPS . The bladder instillation patients received a one-time dose containing 200 mg of lidocaine, alkalinization with tris buffer, and 50,000 units of heparin. Patients were reassessed thirty minutes and one hour after the bladder instillation.
Evaluation and outcome measurements
The patients who received bladder instillations of alkalinized lidocaine and heparin were evaluated with an 11-point analog scale (0-10) for scrotal pain.
|Age (years) of Patient||Duration of Scrotal Pain||Resolution of Scrotal Pain*|
|36||Over 1 year||4 months of therapy: 75% improvement|
|30||15 months||6 months of therapy: 50% improvement|
|43||2 years||6 months of therapy: 50% improvement|
|50||7-8 months||12 months of therapy: 50% improvement|
|42||Over 10 years||9 months of therapy: 50% improvement|
|76||Over 1 year||28 months of therapy: 50% improvement|
|38||8 months||12 months of therapy: 75% improvement|
|44||7 months||12 months of therapy: 100% improvement|
|Age (years) of Patient||Duration and Degree of Initial Scrotal Pain*||Resolution of Scrotal Pain after Bladder Instillation*|
20 years7/10 pain
1 hour5/10 pain
6 months5/10 pain
30 minutes0/10 pain
8 months6/10 pain
30 minutes3/10 pain
>1 year4/10 pain
30 minutes0/10 pain
>1 year5/10 pain
1 hour1/10 pain
>6 months7/10 pain
1 hour3/10 pain
>6 months8-9/10 pain
1 hour3/10 painv
>6 months9/10 pain
1 hour1-2/10 pain
|Characteristic, Median (IQR)||
Pentosan Polysulfate Sodium(n=8)
Bladder Instillation with Alkalinized Lidocaine and Heparin(n=8)
|Duration of scrotal pain (yr)||
|Time to acceptable pain relief||
11 (6-12) months
|60 (30-60) minutes||
|Improvement in pain (%)||
Women with IC/BPS often present with suprapubic, bladder pain. However, multiple pain sites including the external genitalia are common . 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 . 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 . 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. , 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 . Combination of intravesical alkalinized lidocaine and heparin successfully attained immediate and sustained relief of pain in patients with IC/BPS refractory to conventional therapy . 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 . 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.
LIMITATIONS OF THIS STUDY
FINANCIAL SUPPORT AND SPONSORSHIP
CONFLICT OF INTEREST
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Citation:Bosch PC, Parsons LC (2018) Chronic Scrotal Pain: A Variable Symptom of Interstitial Cystitis/Bladder Pain Syndrome. Arch Urol 1: 003.
Copyright: © 2018 Philip C Bosch, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.