Page 6 - Best Practice Report: Canadian Urological Association best practice report on chronic scrotal pain

Jarvi et al

CP/CPPS, although the latter is much more widely studied. of patients had previously received a course of antibiotics,
Research in the treatment of CPPS has shifted towards a suggesting a significant number of patients may have been
biopsychosocial approach. While psychotherapy for psycho- over-treated (Level 3 evidence, Grade C recommendation).
somatic pain disorders has not been well-studied, psycho- In another study, 44 consecutive patients with idiopathic
dynamic psychotherapy may help reduce the impact of the mild to moderate CSP and localized epididymal tenderness
symptoms and improve social/occupational functioning. 44 were treated with oral antibiotics (cephalosporins or qui-
The therapy helps increase the patient’s awareness of mal- nolones as a first choice), as well as cessation of strenuous
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adaptive self-harming behaviours while steering them away activity for four weeks (Level 3 evidence, Grade C recom-
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from catastrophic thinking, leading to pain relief (Level 4 mendation). After this treatment course, all patients were
evidence, Grade C recommendation). fully recovered from scrotal pain and epididymal tenderness.
Cognitive behavioural therapy (CBT) has shown promise While this is a small study, a four-week course of empiric
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in the setting of CP/CPPS. The use of CBT may also help antibiotics is reasonable, especially in patients with tender-
patients challenge pain-distorted thinking, reduce avoidance ness localizable to the epididymis.
of activities based on irrational fear of injury, and may poten- Patients with suspected infectious epididymitis should be
tially increase activity and reduce pain-related limitations 11 treated empirically as per the Centers for Disease Control’s
(Level 4 evidence, Grade D recommendation). guidelines, with coverage of Neisseria gonorrhea and
Summary and recommendations: Lifestyle changes Chlamydia trachomatis in men younger than 35, and cov-
and physical therapies should be first-line therapy in all erage for coliform bacteria in those older than 35 (Level 4
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patients due to the non-invasive nature of treatment. evidence, Grade C recommendation).
Lifestyle changes include modification of aggravating activi-
ties, scrotal support, and heat or cold therapies (Expert Neuropathic medications (four weeks) (Grade 3C)
opinion). Physical therapy and acupuncture may improve In patients with identified neuropathic pain, the recommend-
CSP related to pelvic floor muscle dysfunction or referred ed first-line treatment, as per the Canadian Pain Society
pain from radiculopathies (Level 4 evidence, Grade C rec- consensus statement, consists of anticonvulsants and certain
ommendation). Psychological counselling may help treat antidepressants. 49
maladaptive self-harming behaviours, prevent catastrophic Gabapentin and pregabalin are gabapentinoids that
thinking (Level 4 evidence, Grade C recommendation), and belong to the anticonvulsant class of medications. They have
potentially decrease pain-related physical limitations (Level been studied in large clinical trials largely in the setting
4 evidence, Grade D recommendation). of diabetic neuropathy and post-herpetic neuralgia. Both
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gabapentin and pregabalin bind presynaptic voltage-gated
Medical management calcium channels in the dorsal horn of the spinal cord and
are thought to interfere with pain transmission. In one small,
Non-steroidal anti-inflammatory drugs (NSAIDs) (four weeks) (Grade 4C) retrospective study comparing the efficacy of gabapentin and
There is little specific evidence for the use of NSAIDS in pregabalin in patients with CPPS, gabapentin was found to
the management of CSP and most of the data arises from be significantly more effective than pregabalin at control-
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general chronic pain literature. However, NSAIDs have anti- ling pain. More than 75% of patients on gabapentin alone
inflammatory effects, which may decrease nociceptive pain reported ≥50% improvement in symptoms vs. only 40% on
if there is a component of ongoing inflammation. Failing pregabalin alone, suggesting that gabapentin may be more
conservative strategies, a trial of four weeks of NSAIDs is effective than pregabalin in CPPS (Level 3 evidence, Grade
a reasonable first-line medical therapy (Level 4 evidence, C recommendation).
Grade C recommendation). In another small, retrospective series of 26 patients with
idiopathic CSP, patients who had failed conservative therapies
Antibiotics (four weeks) (Grade 3C) and failed anti-inflammatories and empiric antibiotics were
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While it is common sense that antibiotics should be offered prescribed either gabapentin or nortriptyline. Gabapentin
to patients with culture-proven infectious etiologies of CSP was started at 300 mg daily and titrated by increasing the dose
from their initial evaluation, antibiotics are commonly pre- by 300 mg/day up to a maximum of 1800 mg/day depending
scribed as empiric therapy for CSP as well. However, the on the clinical response and the side effects. Nortriptyline
1
evidence behind this practice is quite limited. In one study was started at 10 mg/day then titrated up to a maximum of
assessing 55 patients presenting with CSP, a detailed infec- 150 mg/day if required. Out of the patients on gabapentin,
tion screen was performed on each patient, including urine 61.5% of patients reported a ≥50% improvement in pain,
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and semen cultures and screening for STIs. Only 12 of the whereas 67% of patients on nortriptyline reported a ≥50%
55 (22%) patients presented with a significant bacterial col- improvement in pain, suggesting that these medications may
ony count considered clinically relevant, while up to 64% be effective in the treatment of CSP, although larger and ide-

166 CUAJ • June 2018 • Volume 12, Issue 6