Opportunities to treat chronic testicular pain in an orthopedic physio practice typically arise incidentally: A patient being treated for something else might ask if there is anything physical therapy can do to help his testicular pain.  Many men are dealing with chronic idiopathic testicular pain [1].  These men have usually been thru the medical system, had all the tests, have seen multiple specialists, have often undergone multiple procedures [2] and have been left without a satisfactory explanation for their symptoms.  Ongoing pain of this sort can significantly affect a patient’s mood and quality of life, creating functional limitations in multiple spheres including work, social, leisure and sexual interactions [3]

I don’t know if testicular pain is a topic covered in current physio degree programs.  In my own schooling, a small fraction of a single anatomy lecture was devoted to the male genital area, and that was it.  There was certainly no discussion about strategies one might use to deal with testicular pain from a physical therapy perspective using existing skills.  That missing discussion is what I hope to provide here.

So, how can a typical orthopedic physical therapist approach testicular pain without special training? 

Musculoskeletal structures can be at the root of testicular pain and these are often (usually?) overlooked in the medical work-up, in which the physical examination is typically limited to the genital region with emphasis on the scrotal contents [4].  Where musculoskeletal structures are contributing to testicular pain, standard orthopedic joint and soft-tissue techniques may be beneficial.

This two-part series will look into these structures, how they relate anatomically to the testicles and interact with one another.  Treatment suggestions and discussion regarding when to refer to a physician or a pelvic health physio are also provided.    

This present article focuses on structures “above the belt”: 

  • Thoracolumbar spine – origin of two of the three nerves that innervate the testicles. 
  • Psoas major – potential restrictor of lumbar movements and compressor testicular nerves. 
  • Iliacus – potential compressor of the inguinal canal (along with psoas). 
  • Abdominal muscles – tissues continuous with the outer layers of the testicles and spermatic cords. 
  • Inguinal canal – a tunnel between abdominal layers through which the testicular nerves and vessels pass.    

Part 2, coming this fall, will delve into the hip and sacroiliac regions.

Incidence & prevalence

Chronic testicular pain can occur at any age, but average age of presentation is mid-40’s [2].  Annual incidence of chronic testicular pain is estimated at 350–450 cases per 100,000 men [5].  Studies suggest that medical workup will find a medical cause for 75-80% these men [6] [7].  The remaining 20-25% with no identified etiology create a significant prevalence of idiopathic chronic testicular pain, making it a relatively common condition. Such patients are excellent candidates for a trial of physical therapy. 

Presenting symptoms

In the literature, testicular pain goes by many different names:  Orchialgia, scrotal pain, scrotal content pain, scrotal pain syndrome, etc.  In this article, “testicular pain” will refer to pain that the patient perceives in the scrotum and/or any of its contents up to and including the inguinal canal. 

Testicular pain can remain localized to the scrotum, or it may radiate into the groin, perineum, sacrum and/or legs [4] [8].  It can be unilateral or bilateral, intermittent or continuous, spontaneous or exacerbated by physical activities and pressure [8] [9].

“Clinicians should be aware that chronic scrotal pain (CSP) is common among men presenting for conditions other than CSP, and that even if the pain levels are not “severe”, the chronic pain often has a significant negative impact on quality of life.”  Conclusion from 2017 Canadian study [1]

Knowing that testicular pain is part of a patient’s presentation may provide important clues about the condition that he’s attending for. Men may not seek treatment for testicular pain [1], and may be reluctant to volunteer information about it.  It becomes the clinician’s responsibility to “start the conversation".

When to ask your male patients if they have testicular pain

  1. When they present with slouched sitting posture, or report that slouched sitting is more comfortable than tall sitting.
  2. Always during lumbar, sacroiliac, groin and hip subjective histories.
  3. When you suspect psoas involvement.
  4. When you suspect abdominal wall involvement.

Prescreening

Sudden, severe testicular pain can be a testicular torsion (twisting of the spermatic cord). This is a medical emergency that can result in permanent tissue damage if it is not treated within a few hours [10]

There are many other potential medical causes for pain in the testicular area (cancer, infection, hernia, trauma, etc.).  As mentioned above, a medical cause is typically found in 75-80% of cases.  Therefore, any patient with a new case of testicular pain should first be screened by his doctor and sent for the appropriate tests and consultations.  However, if the source of the ongoing pain cannot be identified, there’s a reasonable chance that physical therapy can be of assistance.  

It is not necessary for you to examine the testicles themselves, since the doctor will have evaluated any abnormal findings in this area.  In idiopathic testicular pain, aside from possible tenderness, the exam is likely to be unremarkable [8].  If there has been concerning changes in symptoms since the time of the medical workup, have the patient reviewed by the physician before proceeding.  

Subjective history and scan examination 

In the patient’s history, be alert for information about positions or activities that worsen or alleviate the symptoms. 

  • Many men with testicular pain will avoid sitting because it puts pressure on the testicles. When sitting is necessary, they tend to favor a slouched position because it reduces pressure on the anterior pelvic floor compared to sitting upright. 
  • Activities requiring core activation have potential to exacerbate testicular symptoms if abdominal muscle irritability is present.
  • Difficulty with lumbar extension, walking, or lying supine without bending knees may represent iliopsoas or thoracolumbar issues that can drive testicular symptoms.

A lower quadrant scan exam may turn up further clues about positions or movements that exacerbate symptoms, or regional problems that may be related to the presenting symptoms.  Once this is completed, there’s a number of specific areas to examine in more detail.

Thoracolumbar junction 

During fetal development, the testes form along the back wall of the abdomen near the kidneys [11], and then descend from the abdomen into the scrotum shortly before birth. Because of their point of origin, the testes get their somatic innervation from nerves at L1 & L2 levels: the genitofemoral and ilioinguinal nerves.  These nerves innervate the testicles, as well as the anterior scrotum.  [A third nerve (the pudendal nerve) originates sacrally and innervates the posterior scrotum.  It will be discussed in Part 2.]  

Clearing the thoracolumbar junction therefore becomes an important early step [12]. Dysfunction here can irritate the genitofemoral and ilioinguinal nerves as they leave the spine, contributing to testicular pain.  It is helpful to observe what effect any provocative or relieving postures have at the thoracolumbar junction. Stiffness at these segments may benefit from mobilization.  Sometimes it’s stiff segments above or below causing compensatory hinging at the thoracolumbar junction that require attention. 

Psoas major & Iliacus 

Psoas major has a profound impact on thoracolumbar biomechanics.  It originates on T12 thru L5 vertebral bodies, transverse processes and intervertebral discs.  Psoas tension or shortness can pull the lumbar region into increased lordosis, reducing available foraminal space for the exiting nerves at these segments [13].  This is one of several ways that psoas can contribute to testicular pain.

 Psoas major can also compress the ilioinguinal and genitofemoral nerves after they leave the spine, as these nerves pass behind or through the psoas muscle, as shown in Figure 1.

Figure 1: Genitofemoral & Ilioinguinal nerves + Psoas Major

Source: Psoas_Major_video by Kenhub, used under CC_BY_3.0 [Still image extracted & labelled]

The ilioinguinal nerve arises from L1, and emerges from behind (or sometimes piercing through) the lateral border of psoas major, where there’s potential for compression [14]

The genitofemoral nerve arises from L1 & L2, and pierces psoas major, travelling downward within the muscle belly, eventually emerging from its anterior surface…. A path with even greater potential for compression! 

Further down, the relevant branches of the ilioinguinal and genitofemoral nerves pass through the inguinal canal.  Tension or hypertonicity in iliacus and/or psoas can result in compressive force on the posterior wall of the inguinal canal, putting pressure on the canal’s contents, or on the nerves or vessels as they enter the canal.  Travell & Simons [14] describe nerve entrapments that can happen at this interface. 

In addition, the iliopsoas is fascially linked to other structures in the lumbo-pelvic-hip region, such as the hip adductors and pelvic floor [15], which can also contribute to testicular pain. 

Hip flexion strength, as tested during the scan exam, can provide an early indication of iliopsoas’ relationship to the patient’s symptoms.  Iliopsoas flexibility can be assessed using the Thomas test [16].  Sometimes a stretch on the iliopsoas will intensify testicular pain [14]. Palpation of psoas major thru the abdominal wall will sometimes elicit the patient’s usual testicular symptoms.  Travell & Simons [14] provide particularly detailed instructions about how to perform this palpation.

Abdominal muscles 

The abdominal muscles are another primary area to examine in cases of idiopathic testicular pain.  

Although the scrotum hangs down from the pelvic floor, its contents are perhaps best considered akin to abdominal contents. 

During the descent of the testes from the abdomen into the scrotum, each testicle and its accompanying vessels (i.e. vas deferens, and testicular veins, arteries and nerves) become encased in an outpouching of three layers of abdominal tissue: transversalis fascia, internal oblique muscle and external oblique aponeurosis.  Distal to the superficial inguinal ring, the names of these layers change but the tissue layers are continuous, as illustrated in Figure 2.

Figure 2: Schematic diagram showing relationship of abdominal wall to outer layers of spermatic cord

Illustration © 2018, Ann Pisio

Because each testicle is effectively surrounded by extensions of three abdominal muscles, irritability in any of these abdominal layers can be reflected as testicular pain.  For example, experimental injection of hypertonic saline into the external oblique near the ASIS refers pain to the testicle [17]. Web forums abound with reports of testicle pain brought on or worsened by core conditioning exercises.     

In addition to the abdominal layers mentioned above, rectus abdominus can contribute to pubalgia, frequently as a result of muscle imbalance between it and the pelvic floor and/or hip adductors. This typically presents as exercise-related groin pain that can radiate into the testicles [18]

The patient’s symptomatic response to obliques and rectus contractions can be evaluated using a trunk curl with manual resistance provided at one or both shoulders, respectively.  Travell & Simons [17] provide detailed instructions on how to examine the abdominal muscles for trigger points.  They also detail an abdominal tension test to differentiate abdominal wall pain from pain originating in underlying viscera:

  • With patient supine, the tender spot in the abdominal wall is palpated with enough pressure to produce steady pain. 
  • The patient performs either a bilateral leg raise or partial trunk curl to increase abdominal tension while partially unloading underlying viscera from the palpatory pressure. 
  • Increased pain during the contraction implicates the abdominal wall, decreased pain implicates the underlying viscera.

The inguinal canal

There’s a lot going on at the inguinal canal, as shown in Figures 2 & 3.  The inguinal ligament is the floor of the canal, and makes a good landmark.  Superior to this, layers of abdominal muscle and fascia make up the walls of the canal.  Distal of the superficial inguinal ring, this tunnel itself becomes the spermatic cord.  The blood vessels, nerves, and vas deferens run through all or part of this passage.  

Figure 3: Inguinal Canal

Source: Gray, H. (1918) Anatomy of the Human Body, Plate 1146 [public domain]

Any masses, bulging or swelling in this area may represent an inguinal hernia, so refer back to the doctor for further diagnostics if any of these are present.  If the patient has previously had a hernia repair, there may be surgical mesh embedded that is best left undisturbed.  However, in the absence of these, if palpation in the vicinity of the inguinal canal reproduces the patient’s usual symptoms, soft tissue techniques in this area may provide relief.  Barral [19] provides detailed instructions about palpating and treating the superficial inguinal ring with the index finger using the pubic attachment of the inguinal ligament as a landmark. 

Biomechanical treatment

There is a wide variety of treatment approaches within an orthopedic physio’s skillset that can be readily applied to treating issues in the areas discussed above: Joint and soft tissue mobilization, stretching techniques, etc.  

Trigger point release and myofascial techniques can be particularly helpful in stretching and calming the psoas and abdominal muscles.  Davies [20] and Myers [21]  are useful sources of practical techniques of this type. Davies [20] outlines assisted techniques as well as self-applied techniques that can be taught to patients. Diaphragmatic breathing with emphasis on abdominal wall excursion may help reduce abdominal muscle tightness and irritability.

Improving the patient’s sitting posture can be particularly challenging.  Slouched sitting is often more comfortable for the patient, but it can irritate the spine and drive testicular symptoms from there.  Sitting upright with greater anterior pelvic tilt potentially creates heavier pressure on the testicles against the chair.  Here are some possible solutions:

  • BackJoy’s “Posture Plus” is a modified seating device that unweights the perineal area while facilitating tall sitting. 
  • Sitting on a Swiss ball can facilitate upright sitting posture with reduced pressure on the anterior pelvic floor. 
  • “Bladder & Prostate Friendly Chair Cushions” available from www.ic-network.com may be a solution if the patient weighs less than 200 pounds (45 kg). 

Online resources that educate patients about testicular pain tend to focus on medical solutions, or pelvic floor physical therapy interventions.  I’ve posted a patient-centered article at my clinic’s website [LINK] that is more general in its explanation about how physical therapy can be of benefit.  This may be useful in educating patients on their condition, and how orthopedic physiotherapy can be helpful to them.  If you find other useful patient resources elsewhere online, please post links in the comments section below.

Pain treatment

Biomechanical care can have a significant impact on the patient’s presenting symptoms.  However, in many cases, testicular pain will be chronic by the time it ends up in a physio clinic, and as a result, a certain degree of central sensitivity may also be present.  This may limit the effectiveness of a purely biomechanical approach.  As such, appropriate attention should be given to the psychosocial aspects of the presentation, with integration of appropriate pain neuroscience education, CNS quieting techniques, etc. [22] 

When to refer to a pelvic health physio 

Referring the patient to a physical therapist that treats male pelvic health is advisable if there are additional symptoms suggestive of pelvic floor involvement.  Such symptoms could include:

  • Urinary or bowel urgency, frequency or incontinence.
  • Pain, numbness or dysesthesia in the perineum, coccyx or penis.
  • Sexual dysfunction.
  • Symptoms that suggest treatment at or near the testicle might be beneficial (e.g. patient complains of tightness in the spermatic cord).

Additionally, if the patient’s progress plateaus, a second opinion from a pelvic floor therapist may be helpful. 

Coming in Part 2

This “Above the Belt” discussion has covered anatomical structures in the thoracolumbar and abdominal regions that can contribute to testicular pain.  My followup article this fall will discuss “Below the Belt” structures in the sacroiliac and hip regions that can also have an impact.  Again, focus will be on how these structures interact to produce testicular pain, and the sort of techniques that an orthopedic therapist could provide that may result in lasting relief for the patient. 


References

  1. Aljumaily, E. Forbes, H. Al-Khazraji and others, "Frequency and severity of chronic scrotal pain in Canadian men presenting to urologists for infertility investigations," Translational Andrology and Urology, vol. 6, no. 6, pp. 1150-1154, 2017.
  2. S. A. Quallich and C. Arslanian-Engoren, "Chronic testicular pain in adult men, an integrative literature review," vol. 7, no. 5, pp. 402-413, 2013.
  3. L. Levine and M. Hoeh, "Evaluation & Management of Chronic Scrotal Content Pain," vol. 16, no. 36, 2015.
  4. R. Horton, "Physical Therapy Management of Chronic Testicular Pain Impacting Sexual Function: A Case Report," Topics in Geriatric Rehabilitation, vol. 32, no. 3, pp. 182-187, 2016.
  5. R. Strebel, T. Leippold, T. Luginbuehl and others, "Chronic Scrotal Pain Syndrome: Management among Urologists in Switzerland," European Urology, no. 47, pp. 812-816, 2005.
  6. H. Ciftci, M. Savas, E. Yeni and others, "Chronic orchialgia and associated diseases," Current Urology, vol. 4, pp. 67-70, 2010.
  7. Davis, M. Noble, J. Weigel and others, "Analysis & management of chronic testicular pain.," Journal of Urology, no. 143, pp. 936-939, 1990.
  8. P. Granitsiotis and D. Kirk, "ChronicTesticular Pain: An Overview," European Urology, no. 45, pp. 430-436, 2004.
  9. N. Calixte, J. Brahmbhatt and S. Parekattil, "Chronic Testicular & Groin Pain: Pathway to Relief," Current Urology Reports, vol. 18, no. 83, 2017.
  10. M. Boniface and M. Mohseni, "Acute Pain, Scrotum," in StatPearls [Internet], Treasure Island, FL, StatPearls Publishing, 2018.
  11. S. Witchel and P. Lee, "Ambiguous Genitalia," in Pediatric Endocrinology (4e), Saunders, 2014, p. 113.
  12. K. Doubleday, K. Kulig and R. Landel, "Treatment of Testicular Pain Using Conservative Management of the Thoracolumbar Spine: A Case Report," Archives of Physical Medicine & Rehabilitation, vol. 84, no. Dec, pp. 1903-1905, 2003.
  13. S. Sajko and K. Stuber, "Psoas Major: a case report & review of its anatomy, biomechanics, & clinical implications," Journal of the Canadian Chiropractic Association., vol. 53, no. 4, pp. 311-318, 2009.
  14. J. Travell and D. Simons, Myofascial Pain & Dysfunction: The Trigger Point Manual, Vol. 2 (Lower Extremities), Philadelphia: Lippincott, Williams & Wilkins, 1993.
  15. T. Myers, Anatomy Trains (2nd Ed), Toronto: Elsevier, 2009.
  16. Magee, Orthopedic Physical Assessment, Toronto: Elsevier, 2008.
  17. J. Travell and D. Simons, Myofascial Pain & Dysfunction: The Trigger Point Manual, Vol. 1 (Upper Body) (2nd Ed), Philadelphia: Lippincott, Williams & Wilkins, 1999.
  18. J. F. W. Garvey, J. W. Read and A. Turner, "Sportsman hernia: what can we do?," Hernia, no. 14, pp. 17-25, 2010.
  19. J. Barral and A. Croibier, Manual Therapy for the Peripheral Nerves, Toronto: Churchill Livingstone, 2007.
  20. Davies and A. Davies, The Trigger Point Therapy Workbook (3rd Ed), Oakland: New Harbinger, 2013.
  21. T. Myers and J. Earls, Fascial Release for Structural Balance, Berkeley: North Atlantic Books, 2010.
  22. C. Vandyken and S. Hilton, "A Tale of Two Pain States: The Integrative Physical Therapy Approach to the Overactive Pelvic Floor," in The Overactive Pelvic Floor, New York, Springer, 2016, pp. 285-304.