Use of Spermatic Cord Block Systematically Identifies a Paraspinal Tumor as Source of Orchialgia

Case RepoRt Use of Spermatic Cord Block Systematically Identifies a Paraspinal Tumor as Source of Orchialgia Mason Holtel, MD,1 Robert J. Baranello, Jr., MD,1 Allyson Hale, BA,2 Patrick Springhart, MD1,2 1University of South Carolina School of Medicine Greenville, Greenville, SC; 2Regional Urology, Prisma Health System, Greenville, SC Orchialgia is a common urologic complaint with a myriad of etiologies. Workup for orchialgia requires a broad differential diagnosis and a thorough understanding of relevant anatomy. We report the case of a 43-year-old man who presented to a urologist with right testicular pain. Following a negative workup, the patient received a spermatic cord block for therapeutic and diagnostic purposes. Two months after the block, the patient returned with new complaints of ipsilateral inner thigh paresthesias, suggesting a pathologic process proximal to the genital branch of the genitofemoral nerve. A subsequent MRI of the lumbosacral spine revealed a paraspinal mass involving nerve roots at L1-2. We highlight the utility of the spermatic cord block and its role in the diagnosis of a paraspinal tumor as an uncommon cause of orchialgia. [Rev Urol. 2019;21(1):49–52] ® © 2019 MedReviews , LLC KEY WORDS Orchialgia • Spermatic cord block • Genitofemoral nerve • Paraspinal tumor • Testicular pain • Neuropathic pain O rchialgia is a common urologic complaint defined as testicular pain that significantly interferes with activities of daily living. There are several different causes of scrotal pain, yet up to 50% of patients present with an idiopathic etiology.1 Therefore, it is paramount that an extensive differential be considered, and less common causes not be overlooked. We introduce a case of orchialgia in which a spermatic cord block aided in the diagnosis of a paraspinal tumor as the source of a patient’s testicular pain. Case Report A 43-year-old white man with a 7-week history of right-sided testicular pain was referred to a urologist for evaluation. The patient described Vol. 21 No. 1 • 2019 • Reviews in Urology • 49 4170018_13_RIU0828_V1_rev02.indd 49 5/21/19 7:33 PM Paraspinal Mass Presents as Orchialgia continued an intermittent and positional “pinching” pain that seemed to dissipate spontaneously. It was often worse 1 to 2 days following intercourse and ranged from 2 to 7 on a 10-point pain scale. He did not notice any testicular swelling during these episodes and denied any fevers, chills, weight loss, flank pain, dysuria, hematuria, or changes in urinary habits. He also denied any paresthesia involving his genitals, groin, or lower extremities. His past medical history was noncontributory, and he did not have any prior surgeries. His family history was significant only for prostate cancer in his father. Physical examination of the patient was normal. Neither testis showed signs of erythema or swelling and were both nontender to palpation. Examination of the paratesticular structures failed to reveal any masses or abnormalities. Following a negative urinalysis and urine culture, attention was turned to scrotal ultrasound with Doppler flow. There was a normal bilateral echotexture to the testes, and the Doppler study showed appropriate blood flow to both testes and epididymides without signs of ischemia or hyperemia. There were also no masses suggestive of scrotal neoplasm noted on ultrasound. Ten days after initial assessment, the patient returned for a right spermatic cord block with a 0.25% bupivacaine/cortisone solution. Patient follow-up 2 months later revealed significant improvement of his testicular pain following the cord block, but also newly recognized paresthesias of his right medial thigh. He reported that the sensation remained positional, noting that it was exacerbated by movement and alleviated while lying flat. Considering these new findings, an MRI scan of the lumbosacral spine was ordered. Imaging with and without contrast showed a well-circumscribed, heterogeneous, lobulated mass that extended through the neural foramen at L1-2 (Figure 1). The mass measured 1.9 cm 3 2.7 cm with the sagittal sequence showing craniocaudal invasion of 3.0 cm. The patient was referred to neurosurgery, who believed the mass to be a nerve sheath tumor and recommended surgical resection. A Discussion Medical evaluation for orchialgia must cover for a broad differential diagnosis. A pathologic process involving the testicle, epididymis, spermatic cord, vasculature, or local nerve may present as testicular pain. Given our patient’s history of acute testicular pain following sexual intercourse, a workup for an infectious etiology via urinalysis and urine culture was warranted, despite his afebrile presentation and absence of lower urinary tract symptoms. Epididymitis usually presents as gradually increasing unilateral scrotal pain with a tender and swollen epididymis. Patients with epididymitis will also often show increased blood flow on Doppler ultrasound. Ultrasound is also a useful imaging modality for ruling out testicular torsion as a cause of orchialgia. Visualized as impaired blood flow under Doppler ultrasound, testicular torsion classically presents as acute unilateral orchialgia with a highriding testis and absent cremasteric reflex. Associated pain can either be constant or intermittent depending on the degree of torsion. A varicocele may have accounted B Figure 1. Axial MRI of lumbar spine at the level of L1-L2 vertebrae demonstrating a well-circumscribed mass involving the right vertebral foramen. (A) T2-weighted image with contrast; (B) T1-weighted image with contrast. 50 • Vol. 21 No. 1 • 2019 • Reviews in Urology 4170018_13_RIU0828_V1_rev02.indd 50 5/6/19 4:32 PM Paraspinal Mass Presents as Orchialgia for the patient’s positional pain, but it is classically exacerbated by increases in intra-abdominal pressure. Additionally, a palpable “bag of worms” on testicular examination is a classic examination finding caused by abnormally dilated veins and retrograde blood flow.2 Finally, behavioral diagnoses such as malingering or drug seeking should be considered based on history and negative physical examination findings. The ilioinguinal, iliohypogastric, and genitofemoral nerves are primarily responsible for somatic and sensory innervation of the scrotal contents and surrounding cutaneous structures (Figure 2). The genitofemoral nerve is a part of the lumbosacral plexus and is primarily composed of sensory nerve fibers of the L1 and L2 segments of the spinal cord. It is comprised of two branches: the genital branch, which travels through the spermatic cord to innervate the cremasteric muscles and receive sensory input from the scrotum, and the femoral branch, which accompanies the external iliac artery as it receives sensation from the medial thigh. These nerve branches join superiorly to the inguinal ligament, pierce the psoas muscle anteriorly, and emerge posteriorly to enter the spinal cord at L1 and L2. Genitofemoral neuropathies will often involve referred pain along the anatomic distribution of its branches. Originating in 1960 as a local anesthesia procedure for herniorrhaphy, the spermatic cord block has since expanded its clinical use and is involved in a variety of surgical procedures.3 The block aims to relieve pain generated by the genital branch of the genitofemoral nerve.4 Because of its precise localization, the spermatic cord block can be used as both a diagnostic and therapeutic procedure for orchialgia. Figure 2. Anatomical image showing distribution of the ilioinguinal, iliohypogastric, and genitofemoral nerves as well as the cutaneous innervation of the femoral branch of the genitofemoral nerve. Netter illustration used with permission of Elsevier, Inc. All rights reserved. www.netterimages.com. If pain resolves following the block, a diagnosis of neuropathic orchialgia can likely be made. Based on our patient’s isolated testicular pain, we determined that a spermatic cord block was indicated to not only alleviate pain, but also to localize the source of the pain. Once the patient returned with right medial thigh paresthesias suggesting additional femoral branch involvement, the concern was raised for a more proximal source of the patient’s pain. An MRI was ordered to visualize the lumbosacral spine for masses or anatomic abnormalities, leading to the definitive diagnosis. Although the spermatic cord block was not essential for diagnosis, it may have played a role in unmasking the inner thigh paresthesia. It is probable that the patient’s preoccupation with his testicular pain distracted him from his inner thigh involvement. Once the spermatic cord block alleviated Vol. 21 No. 1 • 2019 • Reviews in Urology • 51 4170018_13_RIU0828_V1_rev02.indd 51 5/6/19 4:32 PM Paraspinal Mass Presents as Orchialgia continued the orchialgia, the patient could recognize and report this thigh paresthesia, allowing for a more accurate medical workup. Causes of genitofemoral neuralgia include injury (ie, hernia, surgery, trauma), psoas abscess, foraminal stenosis at L1 and L2, or paravertebral tumor, most likely a peripheral nerve sheath tumor (PNST). PNST is a rare spindle-cell sarcoma that comprises 5% to 10% of all softtissue tumors.5 PNSTs are most commonly found in the retroperitoneum and the lower extremities, although they can arise anywhere in the body given their pluripotent origin.6 As a result, their clinical presentation is often a product of their location, invasion into local structures, or general mass effect. Patients with a PNST will most often present with focal neurologic findings such as weakness, pain, or paresthesias.7 Although malignant tumors may progress rapidly in size, most cases follow a longer, more indolent clinical course. Conclusions The workup of orchialgia requires a broad differential diagnosis due to the wide range of etiologies. A rare paraspinal process causing lumbar nerve root impingement presented itself as a common urologic presentation. One of the key diagnostic factors in the workup of this patient was the proper timing and utilization of a spermatic cord block. The block typically reduces orchialgia symptoms by disrupting sensory information from distal sites such as the testicle, epididymis, and scrotum. In this case, the nerve block likely uncovered the patient’s inner thigh involvement that turned clinical suspicion towards a proximal source of pain. We emphasize a stepwise approach to the diagnosis of orchialgia using both the prevalence of etiologies along with a sound understanding of the nervous system anatomy to isolate the source of pain. Additionally, if spermatic cord block alleviates symptoms and proximal neuropathic etiologies are ruled out, microsurgical denervation of the spermatic cord may be considered. Studies have shown that patients with chronic orchialgia undergo an average of 4.7 to 7.2 diagnostic procedures and 1.6 operative procedures.8,9 This case highlights the importance of the wide differential diagnosis for orchialgia and the spermatic cord block as both a diagnostic and therapeutic intervention. 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