Men who have a tendency towards hypochondria quite often express this by complaining about their testicles. This may relate to a feeling of heaviness, a nagging or a stabbing pain. Complaints about such symp­toms can become a source of frustration for everyone involved, the patient, the gp and the urologist. For the patient because he feels he isn’t being taken very seriously, for the gp because he/she does not know what to do and for the urologist because by the time the patient is referred to him/her a great deal of frustration has built up and the uro­logist knows in advance that no objectively verifiable abnormalities will be found. So we are not talking about the acute pain of a twisted stalk of the testicle or the chronic pain of a swelling in the scrotum; with this pain a physical examination reveals no abnormalities.

Those affected are mostly relatively young, sexually active men, who have intermittent problems. Pain is signalled in one or both testi­cles, sometimes spreading to the groin. It is important to ask certain questions: when does the patient feel pain? Only during the day? Only when sitting for long periods or on the contrary when standing for long periods? Did the problem appear suddenly and continue from then on? Does the testicle pull towards the groin during an attack of pain? Does the pain sometimes pass when the patient is lying down? Has the patient undergone sterilization? Is there also pain during and/or after ejaculation? How frequent are the patient’s ejaculations?

The physical examination of course comprises the careful feeling of the groin, the seminal cord, testicles and epididymides. The epididymis is normally sensitive to the touch, meaning that pain on contact by no means always points to an inflammation. Examination of the patient in a standing position is an absolute must (if medical students omit this in an examination, they fail outright). This can help one diagnose a rup­tured varicose vein as the cause of the nagging pain. In this case the person examining feels and sees a ‘can of worms’ next to the left testicle, which disappears when the patient lies flat.

When the patient is in a lying position the doctor can provoke the cremaster reflex by stroking the inside of the thigh or the lower abdomen. If the testicle pulls towards the groin and this is accompanied by the typical pain, the patient has an exaggerated cremaster reflex: because the muscle fibres are relatively too strong, the testicle is pulled into the groin. Information on this condition is vital; in extreme cases it may be decided to sever the muscle fibres in an operation.

Pain after a hernia operation can also occur and is caused by damage, which may or may not be temporary, to the tiny nerves that run along the inguinal canal to the scrotum. Generally speaking, patients often tell us that they only have a problem when sitting and when asked often turn out to have a sedentary occupation. Examples are taxi drivers, lorry drivers, sales reps, etc. In that case it is good to pay attention to clothing. Tight jeans are fatal to men with testicular pain – jeans are stiff and constrict the testicles.

Often testicular pain is related to sexual activities, since the patient sometimes has more pain during ejaculation or afterwards. It can some­times go on for days. It is not always clear whether this is connected with the degree of arousal, too much or too little sex. Think of Zorba the Greek, who one fine day, after a month of abstinence on an island where he has been doing some building work for an Englishman, says: ‘I’m downing tools, I’m off back to the mainland – my groin is killing me.’

Often testicular pain is accompanied by pain in the area between the anus and the scrotum. This is usually wrongly diagnosed as chronic inflammation of the prostate when it is actually chronic pelvic pain caused by insufficient relaxation of the pelvic floor muscles. Treatment by a physiotherapist in such cases is often much more effective than long-term treatment with antibiotics.

Unfortunately there are by no means always ready-made solutions. Careful gathering of the facts is important, which in practice means taking the time to go through the symptoms and not giving the impression that one is not taking the case seriously. Chronic testicular pain is hard to treat. If the pain really derives from the scrotum and is not referred pain, severing the nerve pathways on a level with the external inguinal ring or a little higher will interrupt the conduction of pain sensation. If a trial blockage high in the seminal cord with a local anaesthetic results in a reduction in pain for the period for which the medication is presumed to work (for example, lidocaine one to two hours, marcaine three to seven hours), there are grounds for severing the nerves (denervation). A ‘positive’ blockage of the nerves in the seminal cord therefore also confirms that the pain actually derives from the scrotum. In addition the blockage has prognostic value for the success of the surgical denervation.

Epididyectomy, or the complete removal of the epididymis, hemi – castration, removal of the testicle with epididymis – and vaso-vasostomy (a restorative operation after sterilization) are also among procedures used to relieve patients’ pain. Hemicastration is the most often recom­mended and most effective procedure. Quite tangentially, it should be mentioned that in the past hemicastration was used to determine the sex of the child to be fathered. If one wanted a boy the man’s left testicle should be tied off. Left was associated with weak and right with strong. The Hottentots used the same method.

In hemicastration an approach through the groin is preferable because it produces better results than via the skin of the scrotum (leav­ing 76% of patients in comparison with 55% permanently pain-free). This difference may perhaps be explained by the high tying off of the seminal cord resulting in the complete severing of the genital branch of the nerve. Sometimes there are good reasons for completely ruling out surgical treatment; in such cases the patient is referred to the pain clinic for psychological treatment and/or medication.