La prise en charge de la douleur testiculaire chronique due a un syndrome de charniere thoraco-lombaire : étude pilote

25 février 2020

Auteurs : F. Aoun, E. Malek, D. Kazan, S. Albisinni, A. Peltier, R. Bollens, T. Roumeguère
Référence : Prog Urol, 2020, 2, 30, 114-118




 




Introduction


Chronic testicular pain is defined as intermittent or constant scrotal or intra-scrotal pain, lasting for 3 months or longer, usually mild in intensity but bothersome to the patient [1]. It is not an infrequent cause of consultation in the urology clinics and often the patient is not satisfied by the care given and the physician is frustrated by the absence of an apparent etiology and an efficacious treatment [2].


Patient's complaint is not limited to the testicle only as the pain may involve other parts of the scrotal content including the epididymis, the spermatic cord and/or the scrotal skin. Physical exam, urine analysis/culture and duplex scrotal ultrasound are mandatory to rule out reversible causes of pain such as tumor, infection, injury, varicocele, spermatocele or infection. Treatment of this problem remains a therapeutic dilemma in the absence of an underlying cause.


The mechanism of testicular pain is not fully understood, but in general involves nociceptors, that are somatic nerves in the genital branch of the genitofemoral and the ilioinguinal nerves, as well as autonomic branches from the parasympathetic ganglia of T10-12 for the testis, and T10-L1 for the epididymis and vas deferens [3, 4]. Thoracolumbar junction syndrome occurs as a result of a minor intervertebral dysfunction at the thoracolumbar junction, and causes pain in the low back, hip, groin, testicles and lower abdomen [5]. A limited number of case reports in the literature demonstrated an improvement of testicular pain after treating the thoracolumbar dysfunction [6, 7, 8, 9].


Herein, we investigated the efficacy of osteopathic diagnosis and treatment of thoracolumbar dysfunction for men with chronic testicular pain.


Materials and methods


Patients


After obtaining the institutional review board approval from our center, a total of 62 patients presenting to our clinic suffering from chronic testicular pain were first included. All patients underwent a standard urologic and osteopathic examination by the same investigator (FA). Anamnesis was taken focusing on the onset, duration, severity (graded on a 0-10 scale on the Visual Analog Scale), and location of pain including points of radiation. Activities that exacerbate or improve the pain such as voiding, bowel movements, sexual or physical activity, prolonged sitting or supine position were noted. Imaging and previous medical treatment and care were also examined. Past surgeries, trauma and infection involving the back, inguinal, scrotal, pelvic or retroperitoneal areas were also noted. Lumbar pain was characterized as well if present. Physical examination focusing on the genitalia, groin and lumbar spine was systematically performed. The aim of the physical exam was to identify any anatomic causes to the pain and to confirm the presence of a thoracolumbar dysfunction. The diagnosis of thoracolumbar dysfunction was based upon physical examination that should reveal severe limitation of the passive and active range of motion of the lumbar spine, tenderness at the T12-L1, L5-S1 and L4-L5 intervertebral spaces and at the T12, L1, L4 and L5 spinous processes. On the ipsilateral side, the maneuver of lateral pressure against the spinous process at the level of T12-L1, the pinch-roll test and the posterior iliac crest point sign should be positive (Figure 1). Additional urine analysis/culture and duplex scrotal ultrasound of the scrotum was ordered to all these patients.


Figure 1
Figure 1. 

Patient is positioned prone (a-b) and left contra-lateral decubitus (c). Various maneuvers are performed to stress the motion segment and elicit pain under examination: extension by slowly applied pressure on the spinous processes, torque, by pressure applied to the sides of the spinous processes and pressure on the facet joint.




Study inclusion


Patients having chronic testicular pain and a thoracolumbar dysfunction were included. Patients with acute or sub-acute testicular pain (less than 3 months) and a thoracolumbar dysfunction were excluded (n =19) and re-included if the pain lasted more than 3 months despite medical therapy (n =11). Patients with chronic testicular pain and no thoracolumbar dysfunction were excluded (n =3). Patients with any related cause of pain were excluded. These included inguinal hernia (n =3), pudendal neuralgia (n =1), varicocele (n =1), prior hernia repair (n =2), prior vasectomy surgery (n =1), infection (n =1) and spermatocele (n =1).


After selection, the severity of the pain was graded using the Visual Analog Scale. Patients were then presented to a physician with an osteopathy training (EM) who evaluated again the severity of the pain using the same scale. A clinical history was taken, with particular attention to life style and musculoskeletal and back symptoms/injuries, followed by a systematic examination (sacroiliac joint and thoracolumbar junction mobility, tenderness on back palpation, posture, range of motion of the hips, spine).


Osteopathic treatment


Each patient was prescribed 1 to 3 treatment sessions, usually at weekly interval, each lasting 15minutes. All manipulations were performed in the same standardized manner by the same operator. An office care including 15minutes of manual flexion-distraction and/or high-velocity, low-amplitude adjustments to palpated restrictions in the lower thoracic and lumbar regions as tolerated by the patient was performed. No instruments were used during the session. No specific physical exercises were needed for home care. However, patients were advised to avoid provocative movements and demonstrated lumbar spine sparing strategies for daily activities. Patients were assessed after the first session to decide if further sessions were needed. The protocol of the study was to perform 3 sessions and if pain persists the osteopathic manipulation was considered as a failed treatment and no further osteopathic manipulation was advised.


Evaluation


After the end of the session, the severity of pain was assessed by the osteopath using the same scale of pain (EM). This allows comparison between the patient's pretreatment and post-treatment perceptions of pain, which is the only important measure at this time. Patients were seen one week after the session by the physician (FA) to assess the severity of pain and decide if further sessions were needed. Patients were then followed-up by regular interval (1 month, and then every three months) and questioned in person or in writing on their pain and satisfaction with the treatment. Patient satisfaction with the treatment was assessed by the following two questions: "if they were satisfied with the treatment" and if they "recommend the treatment for others suffering from the same condition". Cure was defined as a pain scoring 0 on EVA scale. Improvement was considered if a decrease>1 point on EVA scale.


Statistical analysis


Comparison of pain improvement was done using Wilcoxon matched-pairs signed-ranks test. Logistic regression was used to assess for risk factors of success. The studied variables were the site of pain, duration of symptoms, age and severity of pain. A P <0.001 was used for significance.


Results


A total of 41 patients were included (median age 32 years, IQR 24-37). Pain was limited to the head of the epididymis (n =25), head and tail of the epididymis (n =2), scrotal skin (n =2), testicle (n =6), testicle and head of the epididymis (n =6). The pain irradiated to the inner part of the thigh in 8 patients, to the groin in 6 patients, and to both in 4 patients. Lumbar pain was present in 9 patients only.


Duration of symptoms ranged from 3 months up to 6 years (median 4 months, mean 10 months and IQR 3-12 months). All these patients had previously been treated by nonsteroidal anti-inflammatory drugs, muscle relaxant, antidepressants, anticonvulsants, narcotics and/or antibiotics without improvement.


The median Visual Analog scale was 4 (IQR 3-5) before the first session. Four patients included initially did not complete the treatment as planned. A total of 37 patients completed treatment as planned. Patients underwent a median of 2 osteopathic treatment sessions (range 1-3).


After the first session, pain disappeared completely in 14 patients (37.8%). Pain improved significantly in 10 patients (27.1%). A second session was needed for 23 patients (62.2%). After the second session, pain disappeared completely in 9 patients (24.3%) and improved in 7 patients (18.9%). A third session was needed for 14 patients (37.8%). After the third session, pain disappeared completely in 2 patients (5.4%) and improved in 7 patients (18.9%). Improvement after the first, second and third sessions was statistically significant (P <0.001).


Median follow-up was 8 months, (mean 10 months, IQR 5-14 months). At the last follow-up, pain disappeared completely in 25 patients (67.5%) and improvement was noted in 7 patients (18.9%). After initial improvement, two patients experienced pain relapse at their last visit (5.4%). Five patients (13.5%) had no improvement of their symptoms after osteopathic treatment: Two patients had a scrotal skin pain; three patients had long lasting pain limited to the testis (18 months and 72 months, respectively). On multivariate analysis, only the site of pain (Chi2: 18.03, P =0.001) and duration of symptoms (OR 0.72, 95%CI 0.58-0.90, P =0.004) were associated with failure. Age, BMI and severity of pain were not predictors for treatment failure. The treatment was well tolerated; patients were satisfied in 78.1% of cases and recommend the treatment to other person suffering from the same condition in 80.1% of cases (Table 1, Table 2, Table 3).


Discussion


This pilot study describes thoracolumbar junction dysfunction in patients with chronic testicular pain and the diagnostic approach and treatment they received. Thoracolumbar junction dysfunction was present in all but 3 patients with chronic testicular pain unrelated to other etiologies (93.3%). Osteopathic manipulations of the spine resulted in a significant improvement of testicular pain and complete resolution rate as high as 67%.


Thoracolumbar junction syndrome was first described by Robert Maigne as a minor intervertebral dysfunction of the mobile segment of the thoracolumbar junction which consists of the intervertebral disc, ligaments and the facet joints [10]. Minor intervertebral dysfunction causes pain in the corresponding metamere (Figure 1). Afferent innervation of the scrotum originates via somatic nerves in the genital branch of the genitofemoral nerve, ilioinguinal nerves and autonomic branches from T10-L1 parasympathetic ganglia. The genitofemoral and ilioinguinal nerves provide anterior scrotal wall and thigh innervation. The posterior scrotal wall is innervated via the perineal branches of the pudendal nerve. Signs can be found in the same dermatome, myotome and sclerotome as the spinal dysfunction. Therefore, patients may complain of pain in the scrotal skin, epididymis, spermatic cord, and testis. The pain can be felt also on the medial part of the thigh, the groin or lower back [11, 12]. Physical examination is regarded as the keystone for diagnosis of thoracolumbar junction syndrome and should be mastered by the urologist.


Our study is a good example showing that clinical examination is very important when evaluating patients with chronic testicular pain. When examining the thoracolumbar junction, one must always look carefully for tender points upon palpation of spinous processes, transverse process and facet joints. Urologist should look for tenderness at the posterior iliac crest and perform correctly the pinch-roll test described above. Our study demonstrated clearly that clinical assessment is reliable, reproducible and can be done by the trained urologist.


Thoracolumbar junction syndrome is particularly responsive to spinal manipulative therapy [10]. When performed properly, no further treatment is required in most cases as demonstrated in our study. The aim of manipulation is to restore normal mobility to a hypomobile vertebral segment. Long term relief after osteopathic treatment was not assessed in our study due to limited follow-up. Urologist should keep in mind that thoracolumbar junction syndrome is the result of trauma to the spine at that level, efforts, bad postures, and/or repeated micro-trauma. Despite the small number of relapses in our series, relapses could be seen more frequently if long term follow-up was performed. That's why, life style modification, correction and counseling of bad posture, and strengthening spine muscles are mandatory.


Of note, five patients did not respond to osteopathic manipulation. Two patients had a scrotal skin pain that is probably mediated by the pudendal nerve and should be treated accordingly. One patient did have a pudendal nerve infiltration and not >50% improvement on EVA scale. The remaining three patients had a long lasting history of scrotal pain and more severe pain on the Analog Visual Scale and could represent intrinsic neurologic changes (definitive?) more difficult to treat. An infiltration of the posterior articular process at the level of Ll was attempted without any change in testicular pain. Finally, our study is limited by the small number of patients, the absence of a control arm and a relatively short follow-up.


Conclusion


Thoracolumbar junction syndrome is a pathology that should be considered in the differential diagnosis in patients with chronic testicular pain. Physician should be familiar with the above mentioned syndrome and should be able to diagnose and refer for management. The osteopathic treatment of thoracolumbar dysfunction relieves testicular pain in the majority of cases especially if pain is limited to the head of the epididymis and is of short duration.


Disclosure of interest


The authors declare that they have no competing interest.




Table 1 - Baseline patient characteristics.
Number of patients  41 
Age (years) median (IQR)  32 (24-37) 
Site of pain   
Head of the epididymis  25 
Head and tail of the epididymis 
Scrotal skin 
Testicle and head of the epididymis 
Testicle only 
Duration of symptoms (months) median (IQR)  4 (3-12) 
Osteopathic treatment sessions median (IQR)  2 (1-3) 
Visual Analog scale before the first session median (IQR)  4 (3-5) 
VAS-E median (IQR)  6 (5-7) 
VAS p median (IQR)  4 (4-5) 
VAS pp median (IQR)  1 (0-2) 
VAS after 2 days median (IQR)  1 (0-2) 
VAS at 1 month median (IQR)  0 (0-1) 
VAS at 3 months median (IQR)  0 (0-1) 





Table 2 - Association between site of pain and success.
Site  Failure  Success 
Head and tail of the epididymis 
Head of the epididymis and testicle 
Head of the epididymis  25 
Scrotal skin 
Testicle 



Légende :
&khgr;2: 18.03; P =0.001.



Table 3 - Univariate logistic regression exploring risk factors for success.
  OR  95%CI  P -value 
Age  0.99  0.90-1.09  0.85 
Duration of pain  0.72  0.58-0.90  0.004 
VAS  0.58  0.28-1.19  0.14 




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