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Testicular and scrotal pain and related complaints

Primary author: Barry Zevin, MD

Introduction

The prevalence of scrotal contents complaints is unknown, though anecdotally are not rare.

A common cause of scrotal contents pain in transgender women is "tucking," which allows a female-appearing genital contour in tight fitting clothing. Tucking involves manually displacing the testes upward into the inguinal canal, and then positioning the penis and scrotal skin between the legs and rearward toward the anus. Tight underwear, tape or a special garment known as a gaff is then used to maintain this positioning. Many transgender women find this practice to be gender affirming, and may maintain this positioning even at night when asleep. Resulting pain may be traumatic, mechanical or neuropathic. Prolonged tucking may also result in urinary reflux and symptoms of prostatism or even infection such as epididymo-orchitis, prostatitis, or cystitis. Prolonged positioning of a compressed urethral meatus in close approximation to the anus may also serve as a portal of infection. Pain related to the onset of hormone therapy is a common complaint however the etiology of this symptom is unknown.

Acute scrotal contents pain requires a workup to rule out conditions requiring emergency treatment. A physical exam to rule out tumors, hernia, hydrocele or other causes of pain is appropriate. Appropriate imaging should be performed when indicated.[1,2]

Treatment approaches

For acute scrotal contents pain investigation for torsion, infection (especially gonorrhea and chlamydia), inguinal hernia, and occult trauma should be performed when appropriate. If no condition requiring emergency treatment is found, treatment with NSAIDs can be effective.[2]

Counseling and education on safer ways of tucking may be the most effective approach to relieving pain believed to be related to this practice. This might include shorter periods of tucking or less tight tucking. Ready access to transgender surgeries when medically necessary, including orchiectomy and vaginoplasty for the treatment of gender dysphoria, may also minimize this condition.

Chronic orchialgia algorithms for non-transgender men often suggest an empirical course of antibiotics (after attempting diagnosing an etiology) and discourage orchiectomy as a last resort measure. This algorithm may not be appropriate for transgender women. Patients often have gender dysphoria and maybe relieved to be offered orchiectomy (as opposed to non-transgender men, who are typically resistant to even unilateral orchiectomy when indicated); orchiectomy may be raised much higher in the treatment algorithm in these cases. When orchiectomy is not indicated, medications used in the treatment of neuropathic pain may be useful. Pain related to onset of hormone therapy is generally benign, improves spontaneously, and can be treated expectantly and with reassurance.[1,3]

All providers should be aware that physical examination of the genitals may be traumatizing for trans women and must be done with sensitivity and care if necessary. Providers should not discount testicular pain complaints in transgender individuals, and should avoid any perception that transgender women with this complaint are malingering in hope of obtaining an orchiectomy.

References

  1. Keoghane SR, Sullivan ME. Investigating and managing chronic scrotal pain. BMJ. 2010;341:c6716.
  2. Williams DH. How to manage testicular/groin pain: medical and surgical ladder. Urology Times. 2014 Jul 24 [cited 2016 Jan 29].
  3. Levine L. Chronic orchialgia: evaluation and discussion of treatment options. Ther Adv Urol. 2010 Oct;2(5-06):209-14.