Abstract
Objectives:
The purpose of this article is to report the case of a patient who had low-back pain, leg pain, and idiopathic chronic testicular pain and who sought chiropractic care for his low-back and leg pain and received pain relief including his testicular pain.
Subject:
A 36-year-old male patient had low-back pain, right leg pain, and testicular pain that was worsening. All had been present for 5 years. He had been seen by several medical physicians and had lumbar magnetic resonance imaging and x-rays performed. All were read as normal. Examination revealed tenderness of the testicles bilaterally with no masses or other abnormality of the testicles or scrotum. Orthopedic and neurological testing was unremarkable. Tenderness rated 8 out of 10 was noted at the L4 spinous process.
Intervention:
The patient was treated with Cox Technic (flexion-distraction) of the lumbar spine, receiving a total of 19 treatments over an 8-week time period.
Results:
After 4 weeks, the patient's low-back pain was decreased and his leg pain was gone. The testicular pain was improved after the first treatment and gone after 3 weeks of care. The patient was followed up by telephone at 3 and 6 months after discharge to find out if the testicle pain had returned, which it had not.
Conclusions:
This case was one of chronic idiopathic testicular pain. The patient was treated with the Cox Technic, and his low-back pain improved with complete remission of his leg and testicular pain. The testicular pain had not returned 6 months following his discharge from care.
Introduction
The etiology of chronic testicular pain includes local disease, referred pain from other structures, and idiopathic causes. Local causes of pain include both chronic and acute processes such as infection, tumor, torsion, varicocele, hydrocele, spermatocele, polyarteritis nodosa, trauma, and previous surgical procedures. 3 Referred pain as a cause of testicular pain may arise from any structure with the same innervation as the scrotal contents. 4 Testicular pain may arise from the hip, ureter, abdominal viscera, and points of nerve entrapment including disc herniation and peripheral entrapment. 2 Unfortunately, many patients are found to have idiopathic testicular pain.
Management of patients with testicular pain begins with a thorough history and examination including palpation of the scrotum for masses, tenderness, and nodules. Further evaluation may include urinalysis and imaging. Ultrasound of the testes is “the most reliable imaging modality” for testicular pain and is the imaging modality of choice. 2,5 Other types of imaging that may be useful include abdominal ultrasound, computed tomography, and magnetic resonance imaging (MRI). 5 Each of these imaging modalities is used to investigate a specific suspected diagnosis such as aortic aneurysm or disc herniation.
Treatment for testicular pain depends on its cause. For those patients with idiopathic chronic testicular pain, good treatment options may not exist. Surgery should be considered a last resort for these patients. A number of drug approaches exist. Even in patients who do not appear to have an infection, antibiotics may be helpful. 1 Other drugs used include nonsteroidal anti-inflammatory drugs, antidepressants, local anesthetics, and muscle relaxants. 1 For patients who try conservative care but do not respond, there are surgical options that may be considered. These include microsurgical denervation of the spermatic cord, epididymectomy, and vasovasostomy. 1 A final approach for those patients who do not respond to any other treatment is orchiectomy. 1
The purpose of this article is to report on a patient with low-back pain, leg pain, and chronic testicular pain who sought care after finding no relief elsewhere. He had been seen by several medical physicians and had been diagnosed with idiopathic testicular pain.
Case Report
History
The patient was a 36-year-old man with low-back and leg pain who also complained of pain in his right testicle. He described the low-back pain as being in the center and right side of his lumbosacral junction. The leg pain involved the anterior and posterior aspects of his right leg from the buttocks and upper part of his leg down to his foot. He stated that his pain had been present for approximately 5 years, had a sudden onset, but he could not recall a specific incident. The low-back, leg, and testicular pain all started at the same time, but the testicular pain was worsening. He described the testicular pain as a constant dull ache that never remitted. He could not recall any specific activities that aggravated the pain, although ibuprofen helped to relieve it somewhat. His low-back pain was a deep constant ache that intensified to a sharp burning pain when he moved. Standing exacerbated his pain and sitting relieved it. He also had difficulty sleeping due to the back pain. He had undergone cholecystectomy in 2001 and had a hernia repair when he was 13. He had been seen by several medical physicians and had x-rays, urinalysis, and routine blood panels performed. He had also had a lumbar MRI scan 3 years previously. All studies were read as normal. He had been taking 600 mg of ibuprofen for 3 weeks. The ibuprofen helped dull the pain but did not completely relieve it.
Examination
The patient stood 72 inches (183 cm) tall and weighed 190 pounds (86.2 kg). The patient was reluctant to allow examination of the scrotum because his testicles were very sensitive to palpation. Examination revealed tenderness of the testicles bilaterally with no masses or other abnormality of the testicles or scrotum. Examination of the low back and lower extremities was also conducted. Strength, sensation, and reflexes in his lower extremities were normal bilaterally. Orthopedic and neurological testing were unremarkable. Tenderness rated 8 out of 10 was noted at the L4 spinous process. Both L4 and L5 had decreased joint motion. Range of motion was within normal limits with localized, dull “achy” low-back pain on flexion, extension, and right lateral bending at the end of the range of motion. Lumbar range of motion did not aggravate the leg or testicular pain.
Treatment
The patient was a volunteer in an Institutional Review Board–approved study of patients with low-back pain and leg pain. He gave consent to enter the study and to have his data published. The patient was informed that the date of his MRI examination and the nature of his pain indicated that a new MRI scan would be warranted. It was decided to begin care with the understanding that the MRI scan would be ordered if he did not experience any relief within 2 weeks. Because he was treated in a low-back and leg pain study, the treatment provided was dictated by the study design. He was treated with Cox Technic (flexion–distraction) of the lumbar spine, receiving a total of 19 treatments over an 8-week time period. The initial treatments focused on the L4 segment. According to Cox protocol, a contact was taken over the spinous process of the targeted segment while the lower portion of the treatment table (pelvic section) was lowered. This caused a mild flexion of the lumbar spine but more importantly, caused traction of the targeted segment's intervertebral disc. 6 On the third visit, treatment was expanded to include L3 and L5 in addition to L4. The patient reported gradual decrease in pain during the course of his care. On the 18th treatment visit, he reported that his pain was completely gone from the back, leg, and testicle. In accordance with study protocol, he was released from care after 8 weeks (19 treatments). At that time, he reported no leg or testicular pain and only mild back pain.
Outcome measures
The outcomes measured used in the clinical trial were specific to low-back and leg pain. The Oswestry Disability Index (version 2) (ODI), and Numeric Rating Scales (NRS) for low-back and leg pain were administered at the first visit (baseline), and at 4 weeks, and 8 weeks after baseline. The ODI is a valid and reliable outcome measure that is one of the most widely used disability instruments. 7 –10
The level of back and leg pain were rated using NRS. An NRS is an 11-point (0–10) ordinal pain rating scale, which has descriptive anchors below each end of a line. The descriptive anchors are the following: Worst Pain You Have Ever Felt, and No Pain. Above the line are numbers 0–10. Patients are asked to circle a number to indicate their average level of low-back or leg pain over the last week. The NRS is a valid instrument and has been used in low-back trials in the past. 7
For his testicular pain, the patient was asked if the pain was still present at each treatment visit as well as each time that outcome measures were assessed.
Results
At baseline, the patient complained of low-back, leg, and testicular pain. He rated his low-back pain as 6/10 (Table 1). His baseline ODI score was 11. He rated the leg pain as 5/10. At the 4-week assessment, his low-back pain was 3/10, his leg pain was 0, and his ODI score was 10. In his final assessment at 8 weeks, he reported low-back pain of 3/10, leg pain of 0, and an ODI score of 4. After the first treatment he reported decreased back, leg, and testicular pain. After 3 weeks of care, consisting of five treatment visits, the patient reported that his testicular pain was significantly less. After 5 weeks of care (18 treatment visits) he reported no testicular pain at all. Three (3) weeks later at his 8-week assessment, the pain had not returned. The patient was followed up by telephone at 3 and 6 months after discharge to find out whether the testicle pain had returned, which it had not.
ODI, Oswestry Disability Index; NRS, Numeric Rating Scale.
Discussion
The causes of testicular pain are varied, including local diseases, referred pain, and idiopathic causes. The combination of low-back pain and pain in a testicle is a common finding in kidney stones. This case was one of chronic idiopathic testicular pain. The patient had been seen prior to seeking chiropractic care, and causes of pain such as kidney stone or other referred pain from the abdominal viscera had been ruled out. He also did not have any local testicular disease processes such as torsion, tumor, or hydrocele.
The patient was treated with Cox Technic and his low-back pain improved, with complete remission of his leg and testicular pain. The testicular pain had not returned 6 months following his discharge from care. Cox Technic has been shown to be helpful for patients with low-back pain and lower extremity radiculopathy. 11 It can be speculated in this case that irritation of the sacral nerve roots resulted in the patient's testicular pain. The pudendal plexus contains fibers that arise from the 2nd through 4th sacral nerve roots. The scrotal branch of the pudendal nerve innervates the contents of the scrotum. Cox 6 describes a possible mechanism in which a central disc bulge can impinge on sacral nerve roots, resulting in pain of the scrotal contents. In this case, the MRI the patient had was 5 years prior to care and a new MRI was not obtained. Therefore, a central disc bulge at L5 cannot be confirmed nor ruled out. Certainly more research is needed to discover the exact mechanism.
Chiropractors should be aware of the potential causes of testicular pain. Because of the variety of possible sources of referred pain in addition to the local causes of testicular pain, careful evaluation is important. Ruling out serious pathologies should be the first step. In the absence of red flags, conservative treatment of these patients should be considered.
Chiropractors are likely to see patients with chronic testicular pain. These patients may have exhausted all other conservative options and are using chiropractic as a last resort, or the chiropractor may be the first line of investigation.
Limitations
This article illustrates a single case of a patient whose pain improved while under chiropractic care. The decision to initiate treatment without a new MRI scan was consistent with best clinical practice; however, an MRI may have helped lend weight to the authors' theory of why the patient's testicular pain improved. The results this patient obtained cannot be generalized to other patients. This is an area that should be studied further.
Conclusions
This patient experienced complete resolution of his testicular pain lasting at least 6 months following his discharge from care. Chiropractors should perform a careful evaluation of patients with back pain and testicular pain. When the diagnosis is chronic idiopathic testicular pain, chiropractic care may be considered for treatment.
Footnotes
Acknowledgments
The authors would like to acknowledge Dana J. Lawrence, DC, MMedEd, MA. This project was internally funded by the Palmer Center for Chiropractic Research and Palmer College of Chiropractic, Davenport, IA.
Disclosure Statement
No competing financial interests exist.