Pulsed Radiofrequency Ablation for Orchialgia—A Literature Review
Abstract
:1. Introduction
- The ilioinguinal nerve and the genital branch of the genitofemoral nerve innervate the testis’s major somatic sensory innervation. Genital pain, on the other hand, can be felt in any organ or tissue that shares the same L1–L2 or S2–S4 neural pathways as the scrotum or testicles. Orchialgia can be caused by any inflammatory, traumatizing, or infectious stimulus to the scrotal nerves. Testicular pain could be caused by low back pain or radiculitis, which affects the nerve roots from T10 to L1.
- Ureteral stones can produce testicular pain because the testis and the upper ureter have sensory fibers that use spinal cord segments T11 and T12.
- Dysfunction or spasms of the pelvic floor muscles can be linked to CPPS, although they can also occur in some chronic orchialgia patients.
2. Materials and Methods
3. Results
3.1. Clinical Reports on Pulsed Radiofrequency and CSP
3.2. Diagnostic Nerve Block
3.3. Assessment Tool
3.4. Proposed Mechanism of Action of PRF
4. Discussion
5. Conclusions
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
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Inclusion Criteria |
---|
Male gender |
Chronic orchialgia or chronic scrotal pain (CSP) that has been persistent for more than three months |
The patient complained or was diagnosed with CSP |
The patient undergoes pulsed radio-frequency therapy for orchialgia |
Previous patient with hydrocelectomy or varicocelectomy or radical orchiectomy or vasectomy or vasectomy reversal surgery with CSP, (chronic post-surgical chronic scrotal pain), (post-surgical orchialgia), chronic post-groin surgery orchialgia (ilioinguinal and/or the genital branch of the genitofemoral nerves injury during surgical dissections) |
Post-vasectomy pain |
Pain post testicular torsion, pain with varicocele or hydrocele or testicular or epididymal or spermatocele without evidence of infectious causes. |
Patients who showed more than a 50% reduction of their VAS pain score in response to diagnostic spermatic cord block Pain intensity ≥ 5 on the visual analog scale (VAS), pain that lasted for more than 3 months after groin surgeries, failed conservative treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and showed more than 50% reduction of their orchialgia on the VAS for at least 6 h following spermatic cord block with 6 mL of lidocaine 2%. |
Exclusion criteria |
Female gender |
Post herniorrhaphy pain syndrome or inguinodynia, Chronic ilioinguinal neuralgia after inguinal herniorrhaphy, post-traumatic pain, post-abdominal surgery pain, post-abdominal radiation pain, post-cardiac catheterization (inguinal approach) pain, genitofemoral nerve (GFN) neuropathic pain after live laparoscopic donor nephrectomy. |
Patient with the possibility of referred pain, psychiatric problems, malingering associated with chronic pelvic pain or ureteral stone or inguinal hernia or aortic or common iliac artery aneurysms, or lower back disorders. |
Previous hernia, nerve entrapment, chronic inguinal neuropathic pain, chronic inguinal neuralgia, Ilioinguinal neuropathy post pelvic surgery |
Patients with inflammatory causes of scrotal pain, e.g., groin infection, epididymitis, orchitis, and infected hydrocele. |
Patients with coagulopathy, hypertension, ischemic heart disease |
Patients allergic to local anesthetics like lidocaine and concomitant use of NSAIDs or monoamine oxidase inhibitors |
The patient who lost follow-up from the study. |
Author/Year | Country | Study Type/Methods | No. of Patients * | Age Range (Mean, SD) | Presentation and Laterality | Pain Duration (Months) | Follow Up | Outcome |
---|---|---|---|---|---|---|---|---|
Cohen and Foster (2003) [11] | USA | Case report | 1 | 30 | Aching and precipitated by activity. Location: Unilateral (right Side) Risk factor: post vasectomy. | 60 months | 6-months | Patient-reported >90% pain reduction. No complications were reported. |
Misra (2009) [12] | UK | Prospective uncontrolled pilot study | 9 | Mean: 32–65 SD: 10 | Aching, shooting gnawing Sickening Location: Unilateral: 6 Bilateral: 3 | Median 36 months (range 6–120). | 6 months (Range 3–14 months) | Four out of nine patients had complete resolution and one had partial pain relief. One patient reported worse pain Three patients didn’t experience any change. One patient lost follow-up. No complications were observed immediately or during the follow-up period |
Basal (2012) [13] | Turkey | Case series | 5 | Mean: 29 | All patients presented with chronic orchialgia Location: Unilateral: 4 (3 left sides, 1 right side) (Bilateral: 1) | 7.8 months (5–12 months) | 20 ± 2.5 weeks | None of the patients needed any analgesics after the procedure or during the follow-up period. No complications occurred after the procedure. |
Hofmeester (2013) [14] | Netherlands | Case report | 1 | 13 | Pain arose in the right lower quadrant of his abdomen and radiated to the inside of his right upper leg and his right testicle. It was sharp, stinging. It was aggravated by walking, standing, and exercise, and only alleviated by bed rest. Location: Unilateral (Right) | 2 years history of right-sided orchialgia | 12 months | This led to an immediate and lasting decrease in pain of more than 70% as reported by the patient. No complications were reported. |
Terkawi (2014) [15] | Saudi Arabia | Case report | 1 | 17 | Sudden attacks of severe scrotal pain on average once per month which had failed all conservative treatments The pain attacks were associated occasionally with syncopal attacks. Attacks were associated also with the frequency and dripping of urine. The patient could not maintain an erection because of the severe associated testicular pain. Trigger: cold weather Location: Bilateral | Orchialgia had started almost 6 years ago but had become more severe over the last 2 years. | 7 months | After a 7-month follow-up period, the patient reported satisfactory analgesia with a VAS of 0/10 There were no complications, specifically no testicular atrophy or sexual problems, and the cremaster reflex was present bilaterally. |
Hetta 2018 [16] | Egypt | Prospective randomized, double-blind, sham-controlled, clinical trial, | 60, PRF group (n = 30), Sham group (n = 30). | PRF group: 35.8 ± 9.7 Sham group: 37.7 ± 10.4 | pain intensity ≥ 5 on VAS | 3 months post-groin surgery | 3 months | >50% reduction of their VAS pain score was 80% (24/30) in the PRF group versus 23.33% (7/30) in the sham group percentage of patients that did not require analgesic drugs was 50% (15/30) in the PRF group versus 3.3% (1/30) in the sham group. |
Author/Year | Interventions before PRF Treatment | Diagnostic Spermatic Cord Block Method before PRF | PRF Location | PRF Settings |
---|---|---|---|---|
Cohen and Foster (2003) [11] | Previous unsuccessful interventions included: (1) multiple medication trials (failed conservative treatment with antibiotics and nonsteroidal anti-inflammatory analgesics) (2) an ilioinguinal/iliohypogastric nerve block. | Ilioinguinal (T12-L1) nerve, iliohypogastric (T12-L1), and genital branch of the genitofemoral nerve (L1–L2) blocks were performed. | right-sided L1 dorsal root ganglion pulsed RF procedure was attempted (at the next visit) PRF procedures on three different peripherals. nerves—ilioinguinal, iliohypogastric, and genital branch of genitofemoral | 2-Hz frequency, 20-ms pulses in a 1-s cycle, 120-s duration, and 42 °C temperature. Impedance ranged between 200 and 450 Ohms. |
Misra (2009) [12] | Four out of nine patients had previous treatment as follows: (1) Transcutaneous nerve stimulation, ilioinguinal nerve block—no benefit (2) Ilioinguinal nerve block—worse (3) Obturator nerve block, Ilioinguinal nerve block, Injection of pubic tubercle—temporary relief (4) Ilioinguinal and genitofemoral nerve block—50% relief | applied diagnostic cord blockade to all of the patients, who were presented with a resolution of the pain several hours after the blockade | Spermatic cord | RF probe placed percutaneously into the SC was used to deliver four 120-s cycles of 20-millisecond pulses at 2 Hz. |
Basal (2012) [13] | All patients had failed conservative treatment with antibiotic therapy, analgesics, anti-inflammatory agents, or antidepressant drugs. | blockade of the spermatic cord with 0.5% bupivacaine was applied 1 week before the procedure to those patients who did not respond to medical treatment | Spermatic cord | - 2 × 20 ms per second with a generator output (Cosman RFG-1A Lesion Generator, Gulhane Military Medical Academy, Ankara, Turkey) of 45 V for a duration of 3 min at 42 uC. The impedance range was 200–450 V. - outpatient procedure |
Hofmeester (2013) [14] | Pharmacological conservative treatments including acetaminophen, NSAIDs, opiates, and gabapentin, combined with rest did not affect the pain. Transcutaneous electrical nerve stimulation (TENS) reduced the pain to some extent. | With fluoroscopy guidance, each of the dorsal root ganglia of thoracic 12, lumbar 1, and lumbar 2 (Th12, L1, and L2) on the right side was infiltrated with 1 mL of levobupivacaine 0.25%. This resulted in an excellent response lasting 6 h. | Dorsal root ganglia of thoracic 12, lumbar 1, and lumbar 2 (Th12, L1, and L2) on the right side. | (8 min, 2 Hz, 8 ms pulse duration, max 45 V, max 42 °C). |
Terkawi (2014) [15] | Pharmacological conservative treatments (NSAID, Pregabalin, and Tramadol). | With the patient supine and using an aseptic technique, a high-frequency probe (3–12 MHz), (CX50 Philips, Bothell, WA, USA) was used to perform a selective block of the genital branch of the genitofemoral nerve. The area containing the spermatic cord was zoomed by the ultrasound for better visualization of the genital branch of the genitofemoral nerve, which was located lateral to the deferens duct. Local anesthetic injection was performed between the internal and the cremaster fasciae using a 22-gauge insulated needle (in-plane technique), using 20 mg of methylprednisolone and 5 mL of 2.5% bupivacaine bilaterally. The patient reported immediate pain relief that lasted for 6 weeks. | Genital branch of the genitofemoral nerve, which was located lateral to the deferens duct. Ultrasound-guided, pulsed radiofrequency ablation of the genital branch of the genitofemoral nerve. | The patient was counseled on the risks and benefits of thermal ablation using the same ultrasound-guided technique and opted for treatment. For the radiofrequency ablation, a 50 mm, 22 Gauge SMK needle and a 50 mm neuropile connected to the radiofrequency generator (NeuroTherm NT 1100, Wilmington, MA, USA) were used. After sensory and motor stimulation (the latter by watching for cremaster muscle contraction), a PRF of 42 °C was applied for 120 s. |
Hetta 2018 [16] | Failed conservative treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) | spermatic cord block with 6 mL of lidocaine 2%. | PRF was applied to the ilioinguinal nerve and the genital branch of the genitofemoral nerve | voltage output: 40–60 V; 2 Hz frequency; 20 ms pulses in a one-second cycle, 120-s duration per cycle, and 42 °C plateau temperature. PRF was applied for 4 cycles. |
Author/Year | Need of Local Anesthetic Injection before PRF | Procedure Duration | Any Analgesic or Medication Needed Post PRF | Improvement (Perceptible Difference) | Resume Normal Activities | Main Outcome |
---|---|---|---|---|---|---|
Cohen and Foster 2003 [11] | Diagnostic nerve block | 120-s (2 min) | NR | Complete resolution After a 6-month follow-up visit | NR | All 3 patients reported complete pain relief |
Misra (2009) [12] | No local anesthesia | 120 s/cycle for 4 cycles (8 min) | NR | within 2 weeks | They were all able to resume normal activities. | - Four patients described near complete pain relief. - One patient reported partial relief. - Three patients were unaffected. - One reported that he was significantly worse after the procedure. |
Basal (2012) [13] | Diagnostic nerve block | 3 min | Not needed | The mean follow-up period was 20 +− 2.5 weeks. | Just after the procedure | Effective and safe procedure for all patients |
Hofmeester (2013) [14] | Diagnostic nerve block | 8 min | NR | immediate decrease in pain of more than 70% | Immediate | - Pain relief - the patient was very pleased |
Terkawi (2014) [15] | Diagnostic nerve block | 120-s (2 min) | Not used | After 7m complete pain relief. | NR | Seven-month follow-up revealed complete Address for correspondence: satisfactory analgesia. |
Hetta 2018 [16] | Spermatic cord block with 6 mL of lidocaine 2%. | 120 s/cycle for 4 cycles (8 min) | 50% of patients did not require analgesic drugs | The mean VAS pain score reduced from 5.97 to 2.07 by 2 weeks | NR | 80% of patients showed >50% reduction in their VAS pain score |
Author/Year | Standardized Assessment Tools | Score before Pulsed RF | Score after PRF | p-Value |
---|---|---|---|---|
Cohen and Foster 2003 [11] | VAS | Median: 4.33 (4–5) Range: 4–5 | Complete resolution | NR |
Misra (2009) [12] | McGill Pain Questionnaire, And VAS | Median: 7.1 Range: 4.3–8.7 | 4.2 (0–8.6) | NR |
Basal (2012) [13] | VAS | Median: 9 | Mean: 1 | ≤0.05 |
Hofmeester (2013) [14] | VAS | Mean: 8.3 | (Mean 1.6) | NR |
Terkawi (2014) [15] | VAS | VAS: 10/10 | VAS: 0/10 | NR |
Hetta 2018 [16] | VAS GPE | VAS: 5.90 | 2.40 (after 12 weeks) | 0.001 |
Author/Year | Lost Follow-Up Cases | Follow-Up Duration (Months) | Any Analgesic or Medication Needed during the Follow-Up Period | Disease Recurrence | Scrotal Doppler Ultrasonography | Complications |
---|---|---|---|---|---|---|
Cohen and Foster 2003 [11] | 0 | 6 months | NR | No recurrence | Not done | No complications |
Misra (2009) [12] | One patient | Mean 9.6 months. range of 3–14 months | NR | One patient reported some recurrence of pain on the same side a year after treatment, but the pain was much less intense. | Not done | NR |
Basal (2012) [13] | 0 | Mean 20 ± 2.5 weeks. Shortest: 17 weeks Longest: 23 weeks | NR | No recurrence | At 12 weeks post PRF: No pathological changes No Changes in Testicular Volume at 3 months | NR |
Hofmeester (2013) [14] | 0 | 12 months | NR | No recurrence | Not done | No complications |
Terkawi (2014) [15] | 0 | 7 months | NR | No recurrence | Not done | No complications |
Hetta 2018 [16] | 35 patients done RFA, 2 protocol violations, 3 lost of follow-up. Remaining 30 patients | 3 months | Duloxetine as the first line started at 30 mg and increased to 60 mg. Pregabalin as the second line started at 50 mg and increased according to efficacy. Tramadol as the third line started at 50 mg and changed according to efficacy. 15 patients required Analgesia | NR | Not done | NR |
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Alzahrani, M.A.; Safar, O.; Almurayyi, M.; Alahmadi, A.; Alahmadi, A.M.; Aljohani, M.; Almhmd, A.E.; Almujel, K.N.; Alyousef, B.; Bashraheel, H.; et al. Pulsed Radiofrequency Ablation for Orchialgia—A Literature Review. Diagnostics 2022, 12, 2965. https://doi.org/10.3390/diagnostics12122965
Alzahrani MA, Safar O, Almurayyi M, Alahmadi A, Alahmadi AM, Aljohani M, Almhmd AE, Almujel KN, Alyousef B, Bashraheel H, et al. Pulsed Radiofrequency Ablation for Orchialgia—A Literature Review. Diagnostics. 2022; 12(12):2965. https://doi.org/10.3390/diagnostics12122965
Chicago/Turabian StyleAlzahrani, Meshari A., Omar Safar, Muath Almurayyi, Abdulaziz Alahmadi, Abdulrahman M. Alahmadi, Muhannad Aljohani, Abdalah E. Almhmd, Khaled Nasser Almujel, Bader Alyousef, Hussam Bashraheel, and et al. 2022. "Pulsed Radiofrequency Ablation for Orchialgia—A Literature Review" Diagnostics 12, no. 12: 2965. https://doi.org/10.3390/diagnostics12122965