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Interdisciplinary pain management is invaluable to treating refractory orchialgia in children
Christina B. Ching, MD, Heidi A. Stephany, MD, Twila R. Luckett, BSN, RN-BC, Douglass B. Clayton, MD, Stacy T. Tanaka, MD, John C. Thomas, MD, Mark C. Adams, MD, John W. Brock, III, MD, Stephen R. Hays, MD, John C. Pope, IV, MD.
Vanderbilt University, Nashville, TN, USA.
Background:
Testicular and groin pain is a common pediatric urology office complaint. While it requires appropriate evaluation for underlying pathology it can be challenging to treat in the absence of apparent anatomic cause. We hypothesized that pediatric patients with refractory orchialgia are best managed with interdisciplinary pain management and evaluated outcomes in managing such patients in conjunction with our outpatient pediatric pain clinic.
Methods:
Patients evaluated in our pediatric urology clinic between 2002-2012 with ICD code 608.9, Male Genital Disorder NOS, were identified. Patients were included if they presented with orchialgia without identifiable cause and had failed conservative management (rest, scrotal support, Sitz bath, timed voiding, constipation avoidance) including conventional anti-nociceptive analgesics (acetaminophen, non-steroidal anti-inflammatory agents, opioid). Charts were reviewed for patient history, treatment, and outcome.
Results:
30 patients met inclusion criteria. Average patient age was 12.1 years. Average duration of orchialgia was 18.2 months. 36.7% of patients had seen multiple other urologists prior to evaluation in our clinic. Average number of visits to our urology clinic was 2.10 with an average follow-up of 6.74 months (range 0-42.6). 11 patients were lost to follow-up after initial visit. The remaining 19 patients were referred to our outpatient pediatric pain clinic and prescribed empiric anti-neuropathic anti-convulsant (gabapentin) and/or empiric anti-neuropathic anti-depressant (amitriptyline). 1 patient refused to take the medication and was referred to psychiatry. 5 patients (26.3%) responded to medication alone (3 to gabapentin and amitriptyline; 1 to gabapentin alone; 1 to amitriptyline alone); 1 patient continues to take gabapentin while awaiting further follow-up. 10 patients (52.6%) underwent interventional management with nerve block by pediatric anesthesiologists: 8 via ilioinguinal-iliohypogastric blocks, 1 via spinal block, and 1 via epidural block at another facility; 7 patients (70%) undergoing interventional management had resolution of their pain after an average 1.2 blocks and with an average post-block follow-up of 1.68 months (range 0-4.9). 1 patient is awaiting nerve block; 1 patient is not considered an appropriate candidate for interventional management due to a non-anatomic pain distribution of pain.
Conclusions:
Almost two-thirds of children with refractory orchialgia responded to interdisciplinary pain management with referral to our outpatient pediatric pain clinic. Collaboration and early referral can help coordinate care and ease patient suffering. Further follow-up in such patients is warranted.
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