There is a particular frustration in being told that nothing is wrong when something clearly is. Chronic scrotal pain — an ache, a dragging heaviness, or a sharper pain in one or both testicles lasting three months or more — frequently produces a normal examination and a normal ultrasound. Men are sent away reassured, which is the correct clinical conclusion about cancer and infection and entirely unhelpful as an explanation for pain that is still there every day.
It is a more common problem than its low profile suggests, and it is under-reported for obvious reasons. Pain in this part of the body is awkward to describe, awkward to have examined, and easy to postpone. Many men wait a year or more, by which point the pain has usually become harder to treat and has started to affect sitting, driving, work, sleep and sex.
Why the Tests Look Normal
Ultrasound is very good at answering the questions it is designed to answer: is there a tumour, a torsion, an abscess, a hydrocele, a varicocele. It is not designed to show nerve irritation, muscle spasm or pain arising outside the scrotum, and those account for a large share of chronic scrotal pain.
Several mechanisms are recognised. Nerve entrapment or irritation of the genital branch of the genitofemoral nerve or the ilioinguinal nerve can produce pain felt in the testicle while originating in the groin or lower abdomen — a common pattern after hernia repair. Post-vasectomy pain syndrome affects a small minority of men after vasectomy and relates to pressure and inflammation in the epididymis. Referred pain from the lower spine, hip or ureter can present in the scrotum, which is why a kidney stone sometimes announces itself as testicular pain. Chronic pelvic pain syndrome, in which the pelvic floor muscles are persistently overactive, frequently includes scrotal and perineal pain alongside urinary and ejaculatory symptoms. And in longstanding cases, the nervous system itself can become sensitised, so that pain persists after whatever started it has resolved.
A normal ultrasound, in other words, narrows the field considerably. It does not close it.
How It Is Assessed
Assessment is mostly conversation and examination rather than technology. The history matters: how the pain started, whether there was surgery, injury or infection beforehand, what makes it worse, whether it radiates, whether urination, ejaculation or prolonged sitting change it. Examination distinguishes tenderness in the testicle itself from tenderness in the epididymis, the cord, the groin or the pelvic floor, and includes assessment for hernia and for tenderness along the relevant nerves.
Investigation is targeted rather than exhaustive: urine testing and STI screening where relevant, repeat imaging if the picture has changed, and occasionally imaging of the abdomen or spine when the pattern points there. In some cases a diagnostic nerve block is used — local anaesthetic placed around the spermatic cord. Substantial temporary relief points strongly toward a nerve-mediated cause and helps predict which treatments are likely to work.
What Treatment Looks Like
Treatment follows the mechanism. Where the pelvic floor is involved, pelvic floor physiotherapy is often the most effective single intervention and is underused in men. Where nerve pain predominates, medications used for neuropathic pain are more useful than ordinary anti-inflammatories, which frequently do little. Repeated cord blocks help some men. Where an identifiable structural cause exists, targeted surgery — including microsurgical denervation of the spermatic cord in carefully selected cases — can be considered, though it is not a first step.
Progress is often gradual rather than dramatic, and a plan that combines approaches usually outperforms any single one. Persistent pain also takes a toll on mood and sleep, and treating that side is part of treatment rather than a concession that the pain is imagined.
Dr. Raymond Nash assesses testicular and scrotal conditions, including chronic pain that has already been investigated elsewhere, at Grande Prairie Men’s Medical Clinic. Appointments can be made at gpmm.clinic or by calling (587) 416-8296. This article is general information and cannot substitute for an examination of your own case.