title: Interdisciplinary pain management is beneficial for refractory orchialgia in children.
abstract: BACKGROUND
  Idiopathic testicular/groin pain can be a difficult entity for children, their families, and caregivers. The role of interdisciplinary pain management has previously been demonstrated in treating chronic orchialgia at the present pediatric pain clinic.
  
  
  OBJECTIVE
  To evaluate the role of interdisciplinary pain management in managing refractory orchialgia. It was hypothesized that children with refractory orchialgia might respond well. Interdisciplinary care was defined as that which crosses two medical disciplines such as a surgical specialty and specialist in analgesia.
  
  
  METHODS
  Pediatric patients were identified who were: ≥ 10 years old; evaluated in the pediatric urology clinic between 2002 and 2012; were diagnosed wtih ICD code 608.9 or had the diagnosis of male genital disorder NOS. Children were included if they presented with orchialgia without an identifiable cause and failed conservative management (rest, scrotal support, Sitz bath, timed voiding, constipation avoidance) including conventional anti-nociceptive analgesics (acetaminophen, non-steroidal anti-inflammatory drugs, opioids). Patient electronic medical records were reviewed retrospectively.
  
  
  RESULTS
  Twenty-two children met inclusion criteria. Mean age was 13.7 years (range 10-17). Nearly half (45%) of the children had chronic medical conditions such as asthma, allergies, and obesity. Twenty-one of the 22 children were referred to the pediatric pain clinic; 15 were evaluated, and one refused treatment. All children evaluated in the pediatric pain clinic were initially offered an empiric anti-neuropathic anti-convulsant (i.e. gabapentin) and/or an anti-depressant (i.e. amitriptyline) before being offered a nerve block. Of the 14 children accepting treatment in the pediatric pain clinic, six were treated solely with an empiric anti-neuropathic anti-convulsant and/or anti-depressant; eight received medications followed by nerve block (seven ilioinguinal-iliohypogastric blocks, one spinal and ilioinguinal-iliohypogastric block) (see Fig. 1). A total of eight of the 14 children (57%) treated by the pain clinic had resolution of pain, with 50% of those treated with medications alone (three out of six children) responding (two responding to gabapentin and a tricyclic antidepressant, one to gabapentin alone); and five out of eight (63%) treated with medications and then nerve block (ilioinguinal-iliohypogastric block) responding. Of the eight children undergoing nerve block, five required more than one block. The time between each block ranged from 4 to 22.6 weeks. Response to nerve block required an average of 1.4 procedures (range 1-2); mean follow-up after nerve block was 2.4 months (range 0.1-4.8).
  
  
  CONCLUSIONS
  Children with refractory orchialgia often have comorbidities that suggest a multidisciplinary approach would be useful for treating them. The present study found that the majority of children with refractory orchialgia treated in the pediatric pain clinic responded to management. Major limitations, however, included small cohort size and short follow-up, particularly in those children undergoing nerve block. There was also no objective assessment of pain improvement or improvement in quality of life, which could be rectified with a prospective study.
  
  
  CONCLUSIONS
  Collaboration and early referral for interdisciplinary pain management as one of these multidisciplinary approaches may help to coordinate care and ease patient suffering.
authors.affiliation: Division of Pediatric Urology, Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
authors.forename: C B
authors.initials: CB
authors.lastname: Ching
authors.affiliation: Department of Anesthesiology, Vanderbilt University School of Medicine and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA; Department of Pediatrics, Vanderbilt University School of Medicine and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
authors.forename: S R
authors.initials: SR
authors.lastname: Hays
authors.affiliation: Perioperative Services and Pediatric Pain Service, Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
authors.forename: T R
authors.initials: TR
authors.lastname: Luckett
authors.affiliation: Division of Pediatric Urology, Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
authors.forename: M D
authors.initials: MD
authors.lastname: Mason
authors.affiliation: Division of Pediatric Urology, Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
authors.forename: D B
authors.initials: DB
authors.lastname: Clayton
authors.affiliation: Division of Pediatric Urology, Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
authors.forename: S T
authors.initials: ST
authors.lastname: Tanaka
authors.affiliation: Division of Pediatric Urology, Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
authors.forename: J C
authors.initials: JC
authors.lastname: Thomas
authors.affiliation: Division of Pediatric Urology, Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
authors.forename: M C
authors.initials: MC
authors.lastname: Adams
authors.affiliation: Division of Pediatric Urology, Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
authors.forename: J W
authors.initials: JW
authors.lastname: Brock
authors.affiliation: Division of Pediatric Urology, Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA. Electronic address: john.pope@vanderbilt.edu.
authors.forename: J C
authors.initials: JC
authors.lastname: Pope
mesh_terms: D000293:Adolescent; D002648:Child; D002908:Chronic Disease; D006801:Humans; D008297:Male; D059408:Pain Management; D010148:Intractable Pain / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D012189:Retrospective Studies; D013733:Testicular Diseases / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D016896:Treatment Outcome
keywords: Interdisciplinary; Nerve block; Orchialgia; Pain management; Pediatrics