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Orchialgia Presenting with Lower Quadrant Pain in Sitting

      To the Editor:
      A 56-year-old Japanese man with a chief complaint of left lower quadrant pain persisting for about 1 year was referred to our hospital. Because the pain occurred only when the patient was sitting, he spent most of his days standing. He had visited 10 departments (eg, Internal Medicine, Orthopedics, Urology, and Psychiatry) at multiple hospitals before consulting with us; however, laboratory tests, computed tomography, positron emission tomography/computed tomography, upper and lower gastrointestinal endoscopy, and lumbar spine magnetic resonance imaging all failed to identify the cause of his pain. His medical history included hyperuricemia and dyslipidemia, and his family history was unremarkable.
      Although sitting was clearly a pain trigger, sitting upright in a formal Japanese style (seiza) and sitting on the toilet did not induce pain in this patient. This suggested that compression of the buttocks or genitoperineal regions, but not posture, was the cause of the pain. He had no symptoms of the urinary tract, genitalia, or rectum, and no history or risks of sexually transmitted infections were noted. However, he had experienced pain in his left testis for 1 week when he started riding a motor scooter, before he developed left lower quadrant pain. On physical examination, it was found that compression of the left testis induced the left lower quadrant pain, without redness, swelling, skin color change, or varicosis in the testes. Blood tests showed negative results for inflammation, antinuclear antibodies, myeloperoxidase anti-neutrophil cytoplasmic antibody, and proteinase 3-anti-neutrophil cytoplasmic antibody. His urinalysis result was normal, and a urine sample tested after a prostatic massage was not pyuric. Urine culture tests were also negative, and no Chlamydia trachomatis or Neisseria gonorrhoeae was detected on nucleic acid amplification tests. The testicular ultrasound findings were not specific. Oral levofloxacin (500 mg/day for 14 days, withdrawn because of nausea) and cefcapene (300 mg/day for 14 days) did not relieve the pain and led to a diagnosis of idiopathic chronic orchialgia on the basis of a diagnostic algorithm.
      • Heidelbaugh J.J.
      • Llanes M.
      • Weadock W.J.
      An algorithm for the treatment of chronic testicular pain.
      Although the patient did not respond to nonsteroidal antiinflammatory drugs or pregabalin, an epidural block temporarily, but completely, relieved his pain. At the 6-month follow-up after twice-weekly epidural block therapy, the pain reduction was approximately 50%.
      Chronic orchialgia is defined as unilateral or bilateral pain, continuous or intermittent, lasting for at least 3 months and interfering with the daily activities of patients.
      • Heidelbaugh J.J.
      • Llanes M.
      • Weadock W.J.
      An algorithm for the treatment of chronic testicular pain.
      Orchialgia can radiate to the lower abdomen, groin, perineum, back, or legs, and is attributed to the somatic nerve system in the scrotum and testes: the pudendal nerve, derived from S2 to S4, innervates the posterior and inferior scrotum; the ilioinguinal nerve, branching from L1 and L2, innervates the penis root and the upper scrotum; and the genitofemoral nerve, branching from L1 and L2, innervates the cremaster muscle and the parietal and visceral tunica vaginalis.
      • Quallich S.A.
      • Arslanian-Engoren C.
      Chronic testicular pain in adult men: an integrative literature review.
      • Granitsiotis P.
      • Kirk D.
      Chronic testicular pain: an overview.
      This overlapped innervation to the testes and their embryologic origin within the viscera may contribute to a poor localization of pain,
      • Quallich S.A.
      • Arslanian-Engoren C.
      Chronic testicular pain in adult men: an integrative literature review.
      and most patients do not have tenderness of the testis.
      • Granitsiotis P.
      • Kirk D.
      Chronic testicular pain: an overview.
      Contact, sitting, carrying heavy objects, sexual intercourse, and wearing tight underwear are exacerbating factors.
      • Kumar P.
      • Mehta V.
      • Nargund V.H.
      Clinical management of chronic testicular pain.
      Therefore, we considered the patient's left lower quadrant pain as a referred pain of the L1 dermatome caused by testicular compression when sitting. In conclusion, when patients have pain in the lower abdomen that occurs or worsens when sitting, but not when sitting on the toilet, it is important to assess whether the pain is of a testicular origin.

      References

        • Heidelbaugh J.J.
        • Llanes M.
        • Weadock W.J.
        An algorithm for the treatment of chronic testicular pain.
        J Fam Pract. 2010; 59: 330-336
        • Quallich S.A.
        • Arslanian-Engoren C.
        Chronic testicular pain in adult men: an integrative literature review.
        Am J Mens Health. 2013; 7: 402-413
        • Granitsiotis P.
        • Kirk D.
        Chronic testicular pain: an overview.
        Eur Urol. 2004; 45: 430-436
        • Kumar P.
        • Mehta V.
        • Nargund V.H.
        Clinical management of chronic testicular pain.
        Urol Int. 2010; 84: 125-131