Microsurgical Denervation of The Spermatic Cord for Chronic Scrotal Pain: A Prospective Pilot Study

Microsurgical Denervation of The Spermatic Cord for Chronic Scrotal Pain: A Prospective Pilot Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Microsurgical Denervation of The Spermatic Cord for Chronic Scrotal Pain: A Prospective Pilot Study Khaled Almekaty, Amr Raheem, Mohamed Gamal, Maged Ragab, Mohamed Abo El Enein, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8750954/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Microsurgical denervation of the spermatic cord (MDSC) is one of the lines of management of chronic orchialgia, but it has not been fully adopted by different centers. This article reviews a case series experience with a review of literature. Methods This study is a prospective pilot study evaluating the safety and efficacy of MDSC in the management of chronic scrotal pain refractory to conservative management. The study included 30 patients who underwent unilateral MDSC. Efficacy of the technique was evaluated by the degree of pain improvement using the Visual Analogue Scale (VAS) which was done preoperatively and 6 months postoperatively. Safety was assessed by reporting any perioperative complications. Available literature was reviewed looking at safety and efficacy of the technique. Results Twenty patients had complete pain resolution, 5 had a partial but significant resolution of their pain and the pain remained the same in two patients following MDSC. The VAS pain score significantly improved from a median (IQR) of 8.4 (7.0–9.0) to 1.1 (0–9.0) postoperatively (p = 0.0029). No significant complications have been encountered in this study. Conclusions MDSC seems to be a safe and efficacious surgical option for the treatment of refractory chronic scrotal pain (CSP) and should be more widely adopted by specialist centers. chronic scrotal pain chronic orchialgia microsurgical denervation of the spermatic cord Figures Figure 1 Figure 2 Background Chronic scrotal pain (CSP) is defined as intermittent or persistent unilateral or bilateral scrotal pain lasting for more than 3 months and negatively affecting patient’s daily activities and his sense of wellbeing. The prevalence and possible aetiologies of CSP have never been clearly addressed in the literature. However, it represents a challenging problem for both patients and physicians. [ 1 , 2 ] It could be attributed to varicocele, testicular lesions, infection, torsion and detorsion, trauma, vasectomy among other causes. However, 25–50% of cases would be idiopathic and frustrating as no clear treatment approach would be identified. [ 3 , 4 ] Patients with CSP should be systematically evaluated by: accurate history taking; thorough examination; ruling out possible aetiologies by urine culture; scrotal and renal tract scans for local causes; and referred pain from ureters, prostate or lumbar spine. [ 3 , 4 ] The pathophysiology of CSP is still poorly understood. Any damage to any of the scrotal contents; following the above-mentioned possible aetiologies, could lead to peripheral neural injury and Wallerian degeneration and nerve sensitization. [ 5 , 6 ] The initial treatment strategy should be conservative in the form of treatment of the cause if applicable, analgesics, antibiotic trials and alpha blockers. If the response is not satisfactory, the surgical option including the (Microsurgical denervation of the spermatic cord) MDSC could then be considered. [ 7 ] Although some studies have reported the outcomes of MDSC, [ 8 – 18 ] the technique is still not widely adopted in many centers. Therefore, we present this study evaluating the initial outcomes of MDSC, a description of our surgical technique, and a review of the literature. Methods This is a prospective pilot study that was conducted in the urology department of Tanta University in Egypt between August 2022 and August 2024. The study was conducted in accordance with the declaration of Helsinki. The study was approved by the institutional review board of Tanta university (IRB approval number: 34793/7/21). This audit included 30 patients with chronic unilateral scrotal pain more than 6 months and refractory to conservative lines of therapy who underwent MDSC. All patients were assessed by complete history taking, general and local genital examination and scrotal ultrasonography to exclude any treatable cause of their CSP. An ultrasound-guided spermatic cord block was performed at the level of the pubic tubercle using 20 mL of 0.5% bupivacaine to predict the likelihood of success of MDSC. Patients who showed at least 50% reduction in pain were considered suitable candidates for MDSC. All MDSC procedures (Fig. 1 ) were performed by one surgeon, the technique utilized entailed the delivery of the cord through a small 2-cm sub-inguinal skin incision. A 2cm segment of the cremasteric muscle is then excised all around the cord. The fascia covering the cord is then opened, ligated and divided. Using the surgical microscope, the fascia covering the vas is opened and stripped over a 2cm segment with the sparing of the vasal vessels. The internal spermatic veins are ligated and divided with a 2cm segment excised, the tissue in between is also divided with a 2cm segment excised. At the end of the procedure the testicular artery, with its immediate surrounding veins, a few lymphatics, the vas and vasal vessels are spared. All other cord structures are ligated and divided with a 2cm segment excised. We have added a small modification to the technique whereby at the end of the procedure the testis is delivered through the same incision, the tunica vaginalis is opened and 2x2cm piece of tunica is excised with underrunning of the edges in order to avoid postoperative hydrocele (prophylactic hydrocelectomy). Pain improvement was assessed using the visual analogue pain score (VAS) which was completed by patients preoperatively and 6 months postoperatively. We adopted the conclusion of Kelly AM who defined the minimum clinically significant difference (MCSD) in VAS pain score as the mean difference between current and baseline scores when pain is reported as a little better or a little worse. [ 19 ] Differences in MCSD of less than 9mm were unlikely to have clinical significance even if they were statistically significant. Moreover, Intra and postoperative complications were retrieved from patients’ records. All cord structures have been tied and transected with a 2cm segment excised except: sloop 1: vas & vasal vessels, sloop 2: testicular artery with 2 surrounding veins, sloop 3: 3 lymphatic vessels The data collected were organized and entered on Excel sheet and statistically analyzed using SPSS software statistical computer package for Windows, version 25 (IBM Corp., Armonk, N.Y., USA). The Shapiro-Wilk for normality test was performed to assess the distribution of the numerical data. Quantitative data were represented by mean, SD, range, median and interquartile ranges (25th-75thpercentiles). Qualitative data were presented by number and percentage. P ≤ 0.05: is statistically significant. Results Thirty patients with unilateral CSP, not responding to medical treatment were enrolled in the study. 3 cases were excluded from the study as they did not follow up regularly. Idiopathic testicular pain was observed in 20 patients (74.1%). Other identified causes of scrotal pain included post-varicocelectomy pain in 2 patients (7.4%), testicular trauma in 2 patients (7.4%), artificial urinary sphincter surgery in 2 patients, and epididymal cyst excision in 1 patient (3.7%). The median (IQR) age of the studied population was 27.8 ± 5.06 years (ranged from 19 to 39 years). VAS of patients at baseline ranged from 7.0–9.0 with a mean value (± SD) of 8.4 ± 0.31 and the median (IQR) pain duration was 7 (3.5–15) years. Complete pain remission was achieved in 20 patients, while 5 patients had partial but significant improvement. No pain relief was observed in 2 patients. At 6 months postoperatively, VAS scores ranged from 0 to 9, with a mean (± SD) of 1.1 (± 2.26) (Fig. 2 ). This represents both a statistically significant improvement (p = 0.0029) and a clinically significant improvement according to the MCSD. The only complications observed were a small postoperative scrotal hematoma in one patient and a superficial wound infection in another. Both complications were successfully managed with conservative treatment. Discussion Chronic scrotal pain is a condition that causes significant bother to patients and can be quite frustrating to urologists because of the lack of clear management guidelines and the fact that it is idiopathic in up to half of the cases. [ 3 , 4 ] The exact prevalence is not known but it may account to 2.5% of the urology outpatient clinic visits. [ 20 ] Patients should be fully assessed by history taking, physical examination, imaging, urine and semen cultures to rule out treatable aetiologies for the pain. If untreatable cause is identified, initial management includes anti-inflammatory drugs, analgesics, empirical antibiotics and alpha blockers. [ 7 ] Surgery is indicated only after failure of conservative lines of therapy. Surgical options include; vasectomy reversal and/or excision of sperm granuloma in post vasectomy pain, epididymectomy, orchidectomy and MDSC. Vasectomy reversal has a success rate of 69–84%. [ 21 ] However, it will restore the patient’s fertility which is not a convenient option to the patients who originally chose to have a vasectomy. Epididymectomy has a success rate of 10–80% but will only be useful if the pain is confined to the epididymis. [ 22 ] Epididymectomy will also impair the fertility potential and this may not be a good option for younger patients who haven’t completed their family. Orchidectomy is effective in 20–80% of cases but will impair both fertility and testosterone production in addition to the aesthetic and psychological drawbacks. [ 13 , 23 ] Microsurgical denervation of the spermatic cord is another surgical option that can be considered in CSP cases not responding to medical treatment. This technique was first described in 1978 by Devine and Schellhammer. [ 24 ] It has the advantage of not affecting fertility or testosterone production in addition to having a better outcome for pain control. [ 25 ] Chronic scrotal pain is mediated by the spermatic and scrotal branches of the genital branch of genitofemoral nerve, ilioinguinal nerve and sympathetic fibers around testicular arteries. The rationale of the MDSC technique can be justified by the study of Parekattil et al, who found that 84% of the nerve fibers of the spermatic cord in men with CSP showed Wallerian degeneration. Moreover, they described the density of these pathological nerves to be higher within the cremasteric muscle fibers, followed by peri-vasal tissues and least in lipomatous and perivascular tissues (trifecta nerve complex). Thus, cutting the afferent pain pathway signals may lead to down-regulation of the central pain receptors and eventually pain perception control. [ 26 ] After a Medline search, we found 12 studies reporting on the outcome of MDSC (Table 1 ). The studies show that MDSC is effective in 71–96% of the cases and has a complication rate of 0-8.9%. Reported complications include testicular atrophy, hydrocele, haematocele, wound infection and haematoma. [ 8 – 18 ] Table 1 reports on the outcome of MSCD. Study Design Number of testis units Mean follow up in months Efficacy (complete/ partial/ no response) Complications Choa et al, 1992 Prospective 4 18.5 100/0/0 None Cadeddu JA et al, 1999 Retrospective 9 25.1 0/77.8/22.2 None Levine et al, 1996 Prospective 7 16.6 85.7/0/14.3 None Levine LA &Matkov TG, 2001 Prospective 33 20 76/9.1/15 None Heidenreich et al 2002 Prospective 25 31.5 96/0/1 None Strom KH & Levine LA 2008 Prospective 95 20.3 71/17/12 8.9% Testicular atrophy 2, wound inf 2, hydrocele 2, incision hematoma 1 Oliviera et al 2009 Prospective 10 24m 70/20/0 None Parekattil and Gudeloglu, 2013 Prospective 401 23 72/14/14 3% 1 atrophy, 9 hematoma, 2 seroma Cassidy et al, 2015 Prospective 9 3–9 77/22 /1 None Marconi et al 2015 Multicenter open label prospective trial 52 6 80/12/8 4% 1 haematocele, 1 hydrocele Chaudhari et al 2019 Prospective 62 48 81.6/10.5/7.9 superficial wound infection in 3 units, hydrocele in 2 units, seroma in 2 units, and an incisional hematoma in 1 unit In our case series the technique was effective in 25/27 patients with minimal postoperative complications. The extra time and effort taken in sparing some of the lymphatic vessels; in addition to making a fenestration in the tunica vaginalis, which is a modification that we have added to the original technique prevents hydrocele formation. Most experienced microsurgeons should be able to identify and spare the testicular artery however it is important to spare a few veins in order to prevent venous ischaemia. In our technique we spared the veins immediately surrounding the testicular artery which are usually 1–2 veins. Conventional MDSC is performed with surgical microscopes, however, other methods have also been tested. Caddedu et al used a laparoscopic approach while Parekattil and Gudeloglu used a robot-assisted approach on a series of 9 and 401 patients respectively with pain improvement in 77.8 and 86% of the cases respectively. [ 9 , 15 ] Some limitations are in this study. Despite being conducted prospectively, this work should be interpreted as a preliminary, exploratory study. The relatively limited number of patients inevitably restricts the strength of statistical inference and reduces the extent to which the results can be extrapolated to the broader population of patients with CSP. In addition, follow-up was confined to 6 months, which may be insufficient to fully capture late pain recurrence or delayed complications in a condition known for its fluctuating and sometimes relapsing course. Patient inclusion was based on a favorable response to an ultrasound-guided spermatic cord block. While this approach reflects contemporary clinical practice, it introduces an element of selection bias and may have contributed to an overestimation of treatment success when compared with an unselected cohort. Pain evaluation was based predominantly on the VAS, without incorporation of disease-specific or quality-of-life instruments, limiting the assessment to pain intensity rather than the broader functional and psychosocial impact of the intervention. Finally, the absence of a comparator arm and the lack of direct evaluation of the described technical modification prevent firm conclusions regarding its added value over standard microsurgical denervation techniques. Conclusions In this prospective pilot study, MDSC was associated with substantial symptomatic improvement in a carefully selected group of patients with CSP resistant to conservative management, with a low rate of procedure-related morbidity. These early results support the practicality and short-term effectiveness of the technique when performed in specialised settings. Nevertheless, given the exploratory nature of the study, the findings should be viewed as hypothesis-generating rather than definitive. Further prospective studies involving larger cohorts, longer observation periods, and validated patient-reported outcome measures are required to more precisely delineate the role of microsurgical denervation within the surgical management pathway of chronic scrotal pain. Abbreviations CSP Chronic scrotal pain MCSD Minimum clinically significant difference MDSC Microsurgical denervation of the spermatic cord VAS visual analogue score Declarations Ethics approval and consent to participate: An approval was taken from our local ethical committee. Ethical committee approval number: 34793/7/21. Signed consent was taken from the patients. Patients’ confidentiality was kept, and subjects’ names were referred to by plotted numbers in the master table. Consent for publication: A written informed consent was taken from the patients included in this research to publish the data contained within this study. Funding: No funding resources. Author Contribution KhA, MG, MaE, MR, and AG had full access to all the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design were contributed by KhA, AR, and MR. Acquisition of data was contributed by MG, TG, KhA, MaE, and AG. Analysis and interpretation of data were contributed by MG, KhA, AR, and AG. Drafting of the manuscript was contributed by MG, KhA, TG, MaE, and AG. Critical revision of the manuscript for important intellectual content was contributed by KhA, MR, and AG. Statistical analysis was contributed by MG, MR, AR, and MaE. Administrative, technical, or material support were contributed by KhA, MR, AR, and AG. Supervision was contributed by MR and TG, MaE, and KhA. All authors read and approved the final manuscript. Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. References Granitsiotis P, Kirk D (2004) Chronic testicular pain: an overview. Eur Urol 45:430–436 Kumar P, Mehta V, Nargund VH (2010) Clinical management of chronic testicular pain. Urol Int 84:125–131 Ahmed I, Rasheed S, White C, Shaikh NA (1997) The incidence of post-vasectomy chronic testicular pain and the role of nerve stripping (denervation) of the spermatic cord in its management. Br J Urol 79:269–270 Levine LA, Hoeh MP (2015) Evaluation and management of chronic scrotal content pain. Curr Urol Rep 16(6):36 Calixte N, Brahmbhatt J, Parekattil S (2017) Chronic Testicular and Groin Pain: Pathway to Relief. Curr Urol Rep 18(10):83 Belanger GV, VerLee GT, Testicular Pain (2016) Diagnosis and Surgical Management of Male Pelvic, Inguinal, and. Surg Clin North Am 96(3):593–613 Nariculam J, Minhas S, Adeniyi A, Ralph JD, Freeman A (2007) A review of the efficacy of surgical treatment and pathological changes in patients with chronic scrotal pain. BJUI 99:1091–1093 Choa RG, Swami KS (1992) Testicular denervation. A new surgical procedure for intractable testicular pain. Br J Urol 70:417–419 Cadeddu JA, Bishoff JT, Chan DY, Moore GR, Kavoussi RL, Jarrett TW (1999) Laparoscopic testicular denervation for chronic orchalgia. J Urol 162:733–736 Levine L, Matkov TG, Lubenow TR (1996) Microsurgical denervation of the spermatic cord: A surgical alternativein the treatment of chronic orchalgia. J Urol 155:1005–1007 Levine L, Matkov TG (2001) Microsurgical denervation of the spermatic cord as primary surgical therapy for the treatment of chronic orchalgia. J Urol 165:1927–1930 Heidenreich A, Olbert P, Engelmann UH (2002) Management of chronic testalgia by microsurgical testicular denervation. Eur Urol 41:392–397 Strom KH, Levine L Microssurgical denervation of the spermatic cord (MSCD) for chronic orchalgia (2008) Long-term results from a single center. J Urol 180:949–953 Oliveira RG, Camara C, Alves Jde M, Ferreira Coelho RF, Lucon AM, Srougi M (2009) Microsurgical testicular denervation for the treatment of chronic testicular pain initial results. Clin (Sao Paulo) 64:393–396 Parekattil SJ, Gudeloglu A (2013) Robotic assisted andrological surgery. Asian J Androl 15(1):67–74 Cassidy DJ (2015) Early experience with microsurgical spermatic cord denervation for chronic orchialgia at a Canadian centre. Can Urol Assoc J 9(1–2):e72–e74 Marconi M, Palma C, Troncoso P, Oro A, Diemer T, Weidner W (2015) Microsurgical Spermatic Cord Denervation as a Treatment for Chronic Scrotal Content Pain A Multicenter Open Label Trial. J Urol 194(5):1323–1327 Chaudhari R, Sharma S, Khant S, Raval K (2019) Microsurgical Denervation of Spermatic Cord for Chronic Idiopathic Orchialgia: Long-term results from an Institutional Experience. World J Mens Health 37(1):78–84 Kelly AM (1998) Does the clinically significant difference in visual analog scale pain scores vary with gender, age, or cause of pain? Acad Emerg Med 5(11):1086–1090 Strebel RT, Leippold T, Luginbuehl T, Muentener M, Praz V, Hauri D (2005) Chronic scrotal pain syndrome: management among urologists in Switzerland. Eur Urol 47(6):812–816 Myers SA, Mershon CE, Fuchs EF (1997) Vasectomy reversal for treatment of the post-vasectomy pain syndrome. J Urol 157(2):518–520 Siu W, Ohl DA, Schuster TG (2007) Long-term follow-up after epididymectomy for chronic epididymal pain. Urology 70(2):333–335 discussion 335-6 Davis BE, Noble MJ, Weigel JW, Foret JD, Mebust WK (1990) Analysis and management of chronic testicular pain (. J Urol 143(5):936–939 Devine CJ, Schellhammer PF (1978) The use of microsurgical denervation of the spermatic cord for orchalgia. Trans Amer Ass Genito-Uro Surg 70:149 Sibert L, Rigaud J, Delavierre D, Labat J (2010) Therapeutic management of chronic intrascrotal pain. Prog Urol 20(12):1060–1065 Parekattil SJ, Gudeloglu A, Brahmbhatt JV, Priola KB, Vieweg J, Allan RW (2013) Trifecta nerve complex: Potential anatomic basis for microsurgical denervation of the spermatic cord for chronic orchalgia. J Urol 190:265–270 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 02 Mar, 2026 Reviews received at journal 02 Mar, 2026 Reviews received at journal 18 Feb, 2026 Reviewers agreed at journal 15 Feb, 2026 Reviews received at journal 10 Feb, 2026 Reviewers agreed at journal 09 Feb, 2026 Reviewers agreed at journal 09 Feb, 2026 Reviewers invited by journal 08 Feb, 2026 Editor assigned by journal 03 Feb, 2026 Submission checks completed at journal 03 Feb, 2026 First submitted to journal 31 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8750954","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":588776244,"identity":"5f05cec7-6ceb-49eb-8035-b970c997284a","order_by":0,"name":"Khaled Almekaty","email":"","orcid":"","institution":"Tanta University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Khaled","middleName":"","lastName":"Almekaty","suffix":""},{"id":588776245,"identity":"8afb88b7-7c38-4eea-b6c7-d7f6a00d1305","order_by":1,"name":"Amr Raheem","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Amr","middleName":"","lastName":"Raheem","suffix":""},{"id":588776246,"identity":"fa547e2d-bd42-48b8-8dff-173071fa349f","order_by":2,"name":"Mohamed Gamal","email":"","orcid":"","institution":"Tanta University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Gamal","suffix":""},{"id":588776247,"identity":"18ccc168-1586-445f-9f2f-0b248e35c9a7","order_by":3,"name":"Maged Ragab","email":"","orcid":"","institution":"Tanta University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Maged","middleName":"","lastName":"Ragab","suffix":""},{"id":588776250,"identity":"dd5cb45e-6288-4140-bfd7-eac15c9df0d9","order_by":4,"name":"Mohamed Abo El Enein","email":"","orcid":"","institution":"Tanta University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Abo El","lastName":"Enein","suffix":""},{"id":588776251,"identity":"3bfe7d31-5fa4-4fa8-809b-53d4774f4958","order_by":5,"name":"Tarek Gameel","email":"","orcid":"","institution":"Tanta University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tarek","middleName":"","lastName":"Gameel","suffix":""},{"id":588776252,"identity":"6c666c58-e7c9-43a9-99b8-fcd68c1edd8d","order_by":6,"name":"Ahmed Ghaith","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYDCCAwwMzECKsb0BxKtgYDAgWkvPARDvDMlaGNuI0MJ3+wDj58IcG9ke9jOGD3/OOyxvzt58gOFHxTacWiTPJTBLz9yWZtzDk2NsILntsOHOnmMJjD1nbuPUYgB0vTTvtsOJ+xlyzCQMtx1m3HAjx4CZsQ2vFubfvNv+J/bwvzH/kTjnsD0xWtiAthxI7JHIMWM42HA4kaAWSaAWa95tycY9Es+KJRuOpSdvOHMs4SA+v/ABHXabd5udbA9/8saPP2qsbTccbz744EcFbi0MDPwfoAwOUIw0g5kH8KhHBuwPgEQdkYpHwSgYBaNgJAEA4YtdXrGghaYAAAAASUVORK5CYII=","orcid":"","institution":"Tanta University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Ghaith","suffix":""}],"badges":[],"createdAt":"2026-01-31 15:23:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8750954/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8750954/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102553476,"identity":"55d10920-d846-49cf-a2e4-f28cd1e195d7","added_by":"auto","created_at":"2026-02-13 01:14:12","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":86096,"visible":true,"origin":"","legend":"\u003cp\u003eMDSC technique\u003c/p\u003e\n\u003cp\u003eAll cord structures have been tied and transected with a 2cm segment excised except: sloop 1: vas \u0026amp; vasal vessels, sloop 2: testicular artery with 2 surrounding veins, sloop 3: 3 lymphatic vessels\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8750954/v1/4f9ef1ebe7dee98055a45ce8.jpeg"},{"id":102553477,"identity":"4ec1c48e-027b-42da-8d1c-dc8e60f35a9a","added_by":"auto","created_at":"2026-02-13 01:14:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":9595,"visible":true,"origin":"","legend":"\u003cp\u003eBox and Whisker plot showing the postoperative improvement in VAS pain score.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8750954/v1/56b713e75c419dcf41cfb74e.png"},{"id":102553488,"identity":"639426f4-8547-41d4-a6f0-f8a454905703","added_by":"auto","created_at":"2026-02-13 01:14:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":661340,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8750954/v1/907190c3-cd9c-482d-b0f5-e2de85dcea43.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Microsurgical Denervation of The Spermatic Cord for Chronic Scrotal Pain: A Prospective Pilot Study","fulltext":[{"header":"Background","content":"\u003cp\u003eChronic scrotal pain (CSP) is defined as intermittent or persistent unilateral or bilateral scrotal pain lasting for more than 3 months and negatively affecting patient\u0026rsquo;s daily activities and his sense of wellbeing. The prevalence and possible aetiologies of CSP have never been clearly addressed in the literature. However, it represents a challenging problem for both patients and physicians. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIt could be attributed to varicocele, testicular lesions, infection, torsion and detorsion, trauma, vasectomy among other causes. However, 25\u0026ndash;50% of cases would be idiopathic and frustrating as no clear treatment approach would be identified. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003ePatients with CSP should be systematically evaluated by: accurate history taking; thorough examination; ruling out possible aetiologies by urine culture; scrotal and renal tract scans for local causes; and referred pain from ureters, prostate or lumbar spine. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe pathophysiology of CSP is still poorly understood. Any damage to any of the scrotal contents; following the above-mentioned possible aetiologies, could lead to peripheral neural injury and Wallerian degeneration and nerve sensitization. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe initial treatment strategy should be conservative in the form of treatment of the cause if applicable, analgesics, antibiotic trials and alpha blockers. If the response is not satisfactory, the surgical option including the (Microsurgical denervation of the spermatic cord) MDSC could then be considered. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAlthough some studies have reported the outcomes of MDSC, [\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] the technique is still not widely adopted in many centers. Therefore, we present this study evaluating the initial outcomes of MDSC, a description of our surgical technique, and a review of the literature.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is a prospective pilot study that was conducted in the urology department of Tanta University in Egypt between August 2022 and August 2024. The study was conducted in accordance with the declaration of Helsinki. The study was approved by the institutional review board of Tanta university (IRB approval number: 34793/7/21).\u003c/p\u003e \u003cp\u003eThis audit included 30 patients with chronic unilateral scrotal pain more than 6 months and refractory to conservative lines of therapy who underwent MDSC. All patients were assessed by complete history taking, general and local genital examination and scrotal ultrasonography to exclude any treatable cause of their CSP. An ultrasound-guided spermatic cord block was performed at the level of the pubic tubercle using 20 mL of 0.5% bupivacaine to predict the likelihood of success of MDSC. Patients who showed at least 50% reduction in pain were considered suitable candidates for MDSC.\u003c/p\u003e \u003cp\u003eAll MDSC procedures (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) were performed by one surgeon, the technique utilized entailed the delivery of the cord through a small 2-cm sub-inguinal skin incision. A 2cm segment of the cremasteric muscle is then excised all around the cord. The fascia covering the cord is then opened, ligated and divided. Using the surgical microscope, the fascia covering the vas is opened and stripped over a 2cm segment with the sparing of the vasal vessels. The internal spermatic veins are ligated and divided with a 2cm segment excised, the tissue in between is also divided with a 2cm segment excised. At the end of the procedure the testicular artery, with its immediate surrounding veins, a few lymphatics, the vas and vasal vessels are spared. All other cord structures are ligated and divided with a 2cm segment excised. We have added a small modification to the technique whereby at the end of the procedure the testis is delivered through the same incision, the tunica vaginalis is opened and 2x2cm piece of tunica is excised with underrunning of the edges in order to avoid postoperative hydrocele (prophylactic hydrocelectomy).\u003c/p\u003e \u003cp\u003ePain improvement was assessed using the visual analogue pain score (VAS) which was completed by patients preoperatively and 6 months postoperatively. We adopted the conclusion of Kelly AM who defined the minimum clinically significant difference (MCSD) in VAS pain score as the mean difference between current and baseline scores when pain is reported as a little better or a little worse. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Differences in MCSD of less than 9mm were unlikely to have clinical significance even if they were statistically significant. Moreover, Intra and postoperative complications were retrieved from patients\u0026rsquo; records.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAll cord structures have been tied and transected with a 2cm segment excised except: sloop 1: vas \u0026amp; vasal vessels, sloop 2: testicular artery with 2 surrounding veins, sloop 3: 3 lymphatic vessels\u003c/p\u003e \u003cp\u003eThe data collected were organized and entered on Excel sheet and statistically analyzed using SPSS software statistical computer package for Windows, version 25 (IBM Corp., Armonk, N.Y., USA). The Shapiro-Wilk for normality test was performed to assess the distribution of the numerical data. Quantitative data were represented by mean, SD, range, median and interquartile ranges (25th-75thpercentiles). Qualitative data were presented by number and percentage. P\u0026thinsp;\u0026le;\u0026thinsp;0.05: is statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThirty patients with unilateral CSP, not responding to medical treatment were enrolled in the study. 3 cases were excluded from the study as they did not follow up regularly.\u003c/p\u003e \u003cp\u003eIdiopathic testicular pain was observed in 20 patients (74.1%). Other identified causes of scrotal pain included post-varicocelectomy pain in 2 patients (7.4%), testicular trauma in 2 patients (7.4%), artificial urinary sphincter surgery in 2 patients, and epididymal cyst excision in 1 patient (3.7%). The median (IQR) age of the studied population was 27.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.06 years (ranged from 19 to 39 years). VAS of patients at baseline ranged from 7.0\u0026ndash;9.0 with a mean value (\u0026plusmn;\u0026thinsp;SD) of 8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31 and the median (IQR) pain duration was 7 (3.5\u0026ndash;15) years.\u003c/p\u003e \u003cp\u003eComplete pain remission was achieved in 20 patients, while 5 patients had partial but significant improvement. No pain relief was observed in 2 patients. At 6 months postoperatively, VAS scores ranged from 0 to 9, with a mean (\u0026plusmn;\u0026thinsp;SD) of 1.1 (\u0026plusmn;\u0026thinsp;2.26) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This represents both a statistically significant improvement (p\u0026thinsp;=\u0026thinsp;0.0029) and a clinically significant improvement according to the MCSD.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe only complications observed were a small postoperative scrotal hematoma in one patient and a superficial wound infection in another. Both complications were successfully managed with conservative treatment.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e Chronic scrotal pain is a condition that causes significant bother to patients and can be quite frustrating to urologists because of the lack of clear management guidelines and the fact that it is idiopathic in up to half of the cases. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] The exact prevalence is not known but it may account to 2.5% of the urology outpatient clinic visits. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003cp\u003ePatients should be fully assessed by history taking, physical examination, imaging, urine and semen cultures to rule out treatable aetiologies for the pain. If untreatable cause is identified, initial management includes anti-inflammatory drugs, analgesics, empirical antibiotics and alpha blockers. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eSurgery is indicated only after failure of conservative lines of therapy. Surgical options include; vasectomy reversal and/or excision of sperm granuloma in post vasectomy pain, epididymectomy, orchidectomy and MDSC.\u003c/p\u003e \u003cp\u003eVasectomy reversal has a success rate of 69\u0026ndash;84%. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] However, it will restore the patient\u0026rsquo;s fertility which is not a convenient option to the patients who originally chose to have a vasectomy. Epididymectomy has a success rate of 10\u0026ndash;80% but will only be useful if the pain is confined to the epididymis. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Epididymectomy will also impair the fertility potential and this may not be a good option for younger patients who haven\u0026rsquo;t completed their family. Orchidectomy is effective in 20\u0026ndash;80% of cases but will impair both fertility and testosterone production in addition to the aesthetic and psychological drawbacks. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eMicrosurgical denervation of the spermatic cord is another surgical option that can be considered in CSP cases not responding to medical treatment. This technique was first described in 1978 by Devine and Schellhammer. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] It has the advantage of not affecting fertility or testosterone production in addition to having a better outcome for pain control. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eChronic scrotal pain is mediated by the spermatic and scrotal branches of the genital branch of genitofemoral nerve, ilioinguinal nerve and sympathetic fibers around testicular arteries. The rationale of the MDSC technique can be justified by the study of Parekattil et al, who found that 84% of the nerve fibers of the spermatic cord in men with CSP showed Wallerian degeneration. Moreover, they described the density of these pathological nerves to be higher within the cremasteric muscle fibers, followed by peri-vasal tissues and least in lipomatous and perivascular tissues (trifecta nerve complex). Thus, cutting the afferent pain pathway signals may lead to down-regulation of the central pain receptors and eventually pain perception control. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAfter a Medline search, we found 12 studies reporting on the outcome of MDSC (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The studies show that MDSC is effective in 71\u0026ndash;96% of the cases and has a complication rate of 0-8.9%. Reported complications include testicular atrophy, hydrocele, haematocele, wound infection and haematoma. [\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ereports on the outcome of MSCD.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDesign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of testis units\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean follow up in months\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEfficacy\u003c/p\u003e \u003cp\u003e(complete/ partial/ no response)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChoa et al, 1992\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProspective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100/0/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCadeddu JA et al, 1999\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0/77.8/22.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevine et al, 1996\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProspective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e85.7/0/14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevine LA \u0026amp;Matkov TG, 2001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProspective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e76/9.1/15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeidenreich et al 2002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProspective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96/0/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStrom KH \u0026amp; Levine LA 2008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProspective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71/17/12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.9%\u003c/p\u003e \u003cp\u003eTesticular atrophy 2, wound inf 2, hydrocele 2, incision hematoma 1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOliviera et al 2009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProspective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24m\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70/20/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParekattil and Gudeloglu, 2013\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProspective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e401\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72/14/14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003cp\u003e1 atrophy, 9 hematoma, 2 seroma\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCassidy et al, 2015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProspective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e77/22 /1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarconi et al 2015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMulticenter open label prospective trial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e80/12/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003cp\u003e1 haematocele, 1 hydrocele\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChaudhari et al 2019\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProspective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e81.6/10.5/7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003esuperficial wound infection in 3 units, hydrocele in 2 units, seroma in 2 units, and an incisional hematoma in 1 unit\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn our case series the technique was effective in 25/27 patients with minimal postoperative complications. The extra time and effort taken in sparing some of the lymphatic vessels; in addition to making a fenestration in the tunica vaginalis, which is a modification that we have added to the original technique prevents hydrocele formation. Most experienced microsurgeons should be able to identify and spare the testicular artery however it is important to spare a few veins in order to prevent venous ischaemia. In our technique we spared the veins immediately surrounding the testicular artery which are usually 1\u0026ndash;2 veins.\u003c/p\u003e \u003cp\u003eConventional MDSC is performed with surgical microscopes, however, other methods have also been tested. Caddedu et al used a laparoscopic approach while Parekattil and Gudeloglu used a robot-assisted approach on a series of 9 and 401 patients respectively with pain improvement in 77.8 and 86% of the cases respectively. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eSome limitations are in this study. Despite being conducted prospectively, this work should be interpreted as a preliminary, exploratory study. The relatively limited number of patients inevitably restricts the strength of statistical inference and reduces the extent to which the results can be extrapolated to the broader population of patients with CSP. In addition, follow-up was confined to 6 months, which may be insufficient to fully capture late pain recurrence or delayed complications in a condition known for its fluctuating and sometimes relapsing course.\u003c/p\u003e \u003cp\u003ePatient inclusion was based on a favorable response to an ultrasound-guided spermatic cord block. While this approach reflects contemporary clinical practice, it introduces an element of selection bias and may have contributed to an overestimation of treatment success when compared with an unselected cohort. Pain evaluation was based predominantly on the VAS, without incorporation of disease-specific or quality-of-life instruments, limiting the assessment to pain intensity rather than the broader functional and psychosocial impact of the intervention.\u003c/p\u003e \u003cp\u003eFinally, the absence of a comparator arm and the lack of direct evaluation of the described technical modification prevent firm conclusions regarding its added value over standard microsurgical denervation techniques.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this prospective pilot study, MDSC was associated with substantial symptomatic improvement in a carefully selected group of patients with CSP resistant to conservative management, with a low rate of procedure-related morbidity. These early results support the practicality and short-term effectiveness of the technique when performed in specialised settings.\u003c/p\u003e \u003cp\u003eNevertheless, given the exploratory nature of the study, the findings should be viewed as hypothesis-generating rather than definitive. Further prospective studies involving larger cohorts, longer observation periods, and validated patient-reported outcome measures are required to more precisely delineate the role of microsurgical denervation within the surgical management pathway of chronic scrotal pain.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCSP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChronic scrotal pain\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMCSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMinimum clinically significant difference\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMDSC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMicrosurgical denervation of the spermatic cord\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003evisual analogue score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate:\u003c/h2\u003e\n\u003cp\u003eAn approval was taken from our local ethical committee. Ethical committee approval number: 34793/7/21. Signed consent was taken from the patients. Patients\u0026rsquo; confidentiality was kept, and subjects\u0026rsquo; names were referred to by plotted numbers in the master table.\u003c/p\u003e\n\u003ch2\u003eConsent for publication:\u003c/h2\u003e\n\u003cp\u003eA written informed consent was taken from the patients included in this research to publish the data contained within this study.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eNo funding resources.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eKhA, MG, MaE, MR, and AG had full access to all the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design were contributed by KhA, AR, and MR. Acquisition of data was contributed by MG, TG, KhA, MaE, and AG. Analysis and interpretation of data were contributed by MG, KhA, AR, and AG. Drafting of the manuscript was contributed by MG, KhA, TG, MaE, and AG. Critical revision of the manuscript for important intellectual content was contributed by KhA, MR, and AG. Statistical analysis was contributed by MG, MR, AR, and MaE. Administrative, technical, or material support were contributed by KhA, MR, AR, and AG. Supervision was contributed by MR and TG, MaE, and KhA. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGranitsiotis P, Kirk D (2004) Chronic testicular pain: an overview. Eur Urol 45:430\u0026ndash;436\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar P, Mehta V, Nargund VH (2010) Clinical management of chronic testicular pain. Urol Int 84:125\u0026ndash;131\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed I, Rasheed S, White C, Shaikh NA (1997) The incidence of post-vasectomy chronic testicular pain and the role of nerve stripping (denervation) of the spermatic cord in its management. Br J Urol 79:269\u0026ndash;270\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevine LA, Hoeh MP (2015) Evaluation and management of chronic scrotal content pain. Curr Urol Rep 16(6):36\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCalixte N, Brahmbhatt J, Parekattil S (2017) Chronic Testicular and Groin Pain: Pathway to Relief. Curr Urol Rep 18(10):83\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBelanger GV, VerLee GT, Testicular Pain (2016) Diagnosis and Surgical Management of Male Pelvic, Inguinal, and. Surg Clin North Am 96(3):593\u0026ndash;613\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNariculam J, Minhas S, Adeniyi A, Ralph JD, Freeman A (2007) A review of the efficacy of surgical treatment and pathological changes in patients with chronic scrotal pain. BJUI 99:1091\u0026ndash;1093\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoa RG, Swami KS (1992) Testicular denervation. A new surgical procedure for intractable testicular pain. Br J Urol 70:417\u0026ndash;419\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCadeddu JA, Bishoff JT, Chan DY, Moore GR, Kavoussi RL, Jarrett TW (1999) Laparoscopic testicular denervation for chronic orchalgia. J Urol 162:733\u0026ndash;736\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevine L, Matkov TG, Lubenow TR (1996) Microsurgical denervation of the spermatic cord: A surgical alternativein the treatment of chronic orchalgia. J Urol 155:1005\u0026ndash;1007\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevine L, Matkov TG (2001) Microsurgical denervation of the spermatic cord as primary surgical therapy for the treatment of chronic orchalgia. J Urol 165:1927\u0026ndash;1930\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeidenreich A, Olbert P, Engelmann UH (2002) Management of chronic testalgia by microsurgical testicular denervation. Eur Urol 41:392\u0026ndash;397\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrom KH, Levine L Microssurgical denervation of the spermatic cord (MSCD) for chronic orchalgia (2008) Long-term results from a single center. J Urol 180:949\u0026ndash;953\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOliveira RG, Camara C, Alves Jde M, Ferreira Coelho RF, Lucon AM, Srougi M (2009) Microsurgical testicular denervation for the treatment of chronic testicular pain initial results. Clin (Sao Paulo) 64:393\u0026ndash;396\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParekattil SJ, Gudeloglu A (2013) Robotic assisted andrological surgery. Asian J Androl 15(1):67\u0026ndash;74\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCassidy DJ (2015) Early experience with microsurgical spermatic cord denervation for chronic orchialgia at a Canadian centre. Can Urol Assoc J 9(1\u0026ndash;2):e72\u0026ndash;e74\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarconi M, Palma C, Troncoso P, Oro A, Diemer T, Weidner W (2015) Microsurgical Spermatic Cord Denervation as a Treatment for Chronic Scrotal Content Pain A Multicenter Open Label Trial. J Urol 194(5):1323\u0026ndash;1327\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaudhari R, Sharma S, Khant S, Raval K (2019) Microsurgical Denervation of Spermatic Cord for Chronic Idiopathic Orchialgia: Long-term results from an Institutional Experience. World J Mens Health 37(1):78\u0026ndash;84\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelly AM (1998) Does the clinically significant difference in visual analog scale pain scores vary with gender, age, or cause of pain? Acad Emerg Med 5(11):1086\u0026ndash;1090\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrebel RT, Leippold T, Luginbuehl T, Muentener M, Praz V, Hauri D (2005) Chronic scrotal pain syndrome: management among urologists in Switzerland. Eur Urol 47(6):812\u0026ndash;816\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMyers SA, Mershon CE, Fuchs EF (1997) Vasectomy reversal for treatment of the post-vasectomy pain syndrome. J Urol 157(2):518\u0026ndash;520\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiu W, Ohl DA, Schuster TG (2007) Long-term follow-up after epididymectomy for chronic epididymal pain. Urology 70(2):333\u0026ndash;335 discussion 335-6\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavis BE, Noble MJ, Weigel JW, Foret JD, Mebust WK (1990) Analysis and management of chronic testicular pain (. J Urol 143(5):936\u0026ndash;939\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDevine CJ, Schellhammer PF (1978) The use of microsurgical denervation of the spermatic cord for orchalgia. Trans Amer Ass Genito-Uro Surg 70:149\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSibert L, Rigaud J, Delavierre D, Labat J (2010) Therapeutic management of chronic intrascrotal pain. Prog Urol 20(12):1060\u0026ndash;1065\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParekattil SJ, Gudeloglu A, Brahmbhatt JV, Priola KB, Vieweg J, Allan RW (2013) Trifecta nerve complex: Potential anatomic basis for microsurgical denervation of the spermatic cord for chronic orchalgia. J Urol 190:265\u0026ndash;270\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"african-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"afju","sideBox":"Learn more about [African Journal of Urology](http://link.springer.com/journal/12293)","snPcode":"12301","submissionUrl":"https://submission.springernature.com/new-submission/12301/3","title":"African Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"chronic scrotal pain, chronic orchialgia, microsurgical denervation of the spermatic cord","lastPublishedDoi":"10.21203/rs.3.rs-8750954/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8750954/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMicrosurgical denervation of the spermatic cord (MDSC) is one of the lines of management of chronic orchialgia, but it has not been fully adopted by different centers. This article reviews a case series experience with a review of literature.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study is a prospective pilot study evaluating the safety and efficacy of MDSC in the management of chronic scrotal pain refractory to conservative management. The study included 30 patients who underwent unilateral MDSC. Efficacy of the technique was evaluated by the degree of pain improvement using the Visual Analogue Scale (VAS) which was done preoperatively and 6 months postoperatively. Safety was assessed by reporting any perioperative complications. Available literature was reviewed looking at safety and efficacy of the technique.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwenty patients had complete pain resolution, 5 had a partial but significant resolution of their pain and the pain remained the same in two patients following MDSC. The VAS pain score significantly improved from a median (IQR) of 8.4 (7.0\u0026ndash;9.0) to 1.1 (0\u0026ndash;9.0) postoperatively (p\u0026thinsp;=\u0026thinsp;0.0029). No significant complications have been encountered in this study.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eMDSC seems to be a safe and efficacious surgical option for the treatment of refractory chronic scrotal pain (CSP) and should be more widely adopted by specialist centers.\u003c/p\u003e","manuscriptTitle":"Microsurgical Denervation of The Spermatic Cord for Chronic Scrotal Pain: A Prospective Pilot Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-13 01:13:56","doi":"10.21203/rs.3.rs-8750954/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-03T03:33:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-02T19:45:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-18T18:45:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"232564011820063441473584672157190508801","date":"2026-02-15T18:26:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-10T07:24:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"190495871834781682901402750452761119973","date":"2026-02-09T18:55:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"145454272443674841271172950572259268101","date":"2026-02-09T12:23:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-08T23:08:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-03T12:24:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-03T12:23:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"African Journal of Urology","date":"2026-01-31T15:13:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"african-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"afju","sideBox":"Learn more about [African Journal of Urology](http://link.springer.com/journal/12293)","snPcode":"12301","submissionUrl":"https://submission.springernature.com/new-submission/12301/3","title":"African Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"51c7ca81-3394-4eca-86cf-ccadd590cd10","owner":[],"postedDate":"February 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T20:54:00+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-13 01:13:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8750954","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8750954","identity":"rs-8750954","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}