How it started / how it's been treated

It all started after having been out of work for close to a year last September (2005). I wasn't coping very well and had pretty much ceased all of my usual physical activity for several months (I was previously a VERY active badminton player). I had begun putting on enough pounds that I was motivated to start an exercise regimen. I lived in a 19 floor apartment building, so I started climbing to the roof everyday. I gradually built up from one climb a day with several stops to four times daily with no stops. A couple of times, I had a sharp pain in the testicles that stopped me cold, but after about 5 seconds it went away. I chalked it up to "yet another weird thing my body does occasionally". Then one day, they started feeling funny, as if they were heavier than normal. Over the course of a week, they just became more and more noticeable. Then one morning, it was suddenly painful to even walk across the room, and my upper inner thighs were numb and tingling. An ultrasound at the local hospital left docs unsure of whether it was a varicocele or epididymitis, so they gave me a week of Levofloxacin. I came back a week later with no improvement and saw a different doc, who said the first doc didn't know what he was talking about, and immediately placed me on an IV (cefotaxime) for 5 hours, saying that if I felt any better the next morning, I should come back for IV treatment for the next 7 days. IV treatment is a miserable affair in China, and since I lived just across the border from Hong Kong at that time, I hopped on over the next day to see my doctor there. He referred me to a urologist who quickly concluded via manual / visual examination that I had a varicocele; RX: take acetaminophen as needed and lay down with legs raised. "It's nothing serious".

Within a week, things DID improve. Pain ceased to be a constant companion - as long as I didn't walk or stand for too long. All the symptoms did seem to point to a varicocele. I figured I'd just have to live with it until I found work again.

I took a job in Shanghai in March 2006 and quit a month later because the travel requirements made my two little companions unbearable. The first urologist I saw in Shanghai did a manual exam, said "Epididymitis!", threw some antibiotics at me, and rushed me out the door. The second was a little more thorough, doing testicular and prostate ultrasounds. The testicular showed no abnormalities, and the prostate showed none either although something about an echo was a little off. This doc concluded I had prostatitis (despite the lack of urinary or perianal symptoms) and gave me some pills (English name was Prostat) which are some kind of pollen primarily. I took those for 4 days, but from the very first day developed urethral irritation (felt like there was sand in there) and a slight burning sensation at the tip similar to what I get if I urinate too soon after ejaculating. Once I quit the Prostat, that problem went away.

I then saw an internal medicine specialist who said that epididymitis and prostatitis were related and not much was known about either; he thought my case could be caused by my stair-climbing. He gave me ibuprofen and said if that didn't work to try diclofenac. Beyond that, he said, suggested that I consider going to Hong Kong or back to the US for treatment, as he didn't know of any urologists here that are up to the task. I saw a previous urologist again not long after, and he gave me tramadol, which doesn't really kill pain but makes me just not give a damn about it. Unfortunately, it also half-zombifies me for about 24 hours and gives me arrhythmia, which in turn sometimes makes me nauseous. I use it only as a last resort.

Around this time I started to develop a severe case of what I now believe was reactive arthritis in my hands. It got so bad I couldn't even type. I got desperate and went to a TCM doctor who said my problem had to do with diet. He put me on a very foul diet of nuts and beans for a week. It didn't work, so I went back and he put me on a couple of different herb balls. Within a week, my arthritis cleared up completely, but it had no effect on my testicular pain.

Not long after this, my copy of Headache In The Pelvis arrived, and reading it prompted me to look around for a good physical therapist. Somehow I managed to get referred to a hospital here to see a Hong Kong based sports medicine doctor in late July who found a hip problem that could possibly be the cause of my pain. Here's an exerpt from his report:

On examination: Positive findings: irritable right hip on flexion with adduction and internal rotation. Negative findings: normal FABER tests both hips. Normal gait. Normal testes. No significant herniae. Back, SI joints and buttock muscles normal.

X-ray: AP pelvis and hips and frog laterals: show a Ganz lesion of the right proximal femur with a pistol grip (aka phalloid) deformity.

Injection: local anaesthetic and steroid to the right hip: he found the injection uncomfortable and it was not possible to place the entire injection intraarticularly, reexamination showed a slight improvement in hip impingement.

Impression: he has cam impingement, a form of femoro-acetabular impingement (FAI). This condition could certainly cause the testicular pain, however, it is possible that it could be an alternative underlying cause, such as a sports hernia. Unfortunately the local anaesthetic component of the hip injection was non-diagnostic, but I hope that the steroid component will reduce his pain over the next few weeks.

FAI is a recently recognised condition, and most likely causes arthritis of the hip.
Recommendation: hip arthroscopy to remove the Ganz lesion and deal with any secondary articular cartilage damage to the acetabular labrum.

Plan: if his pain settles with the injection, it would be reasonable to proceed directly to arthroscopy, if the pain does not settle it would be reasonable to repeat the injection or perform MRI of the hip and pelvis to rule out alternative problems such as avascular necrosis of the femoral head, musculo-skeletal pelvic tumour etc.

Information: I have asked him to visit www.hipfai.com for further information.

Physiotherapy: FAI cannot be treated by physiotherapy, but the physiotherapist may be able to relieve his, presumably secondary, muscle spasm and reinforce the importance of avoiding positions of hip impingement (i.e. flexion +/.adduction +/.internal rotation).

I must say it was a real relief to see a doctor that actually listened and was willing to explore the possibility that there may be causes outside of the urological sphere (I sure had a tough time explaining that to the nurse who was charged with conveying the general nature of my problem to the doctor before he saw me though!). After that visit, I began doing the stretches recommended in A Headache In The Pelvis, but stopped after a week or so as it seemed to be making things worse. I have not been back to see this physician since because I'm not entirely convinced that an impingement is my problem. It doesn't explain why the testicles are tender to the touch when flare-ups occur.

In early August, I saw yet another TCM doctor who said the problem was that too much heat and dampness was trapped down there. He prescribed some herbs that were, in the end, profoundly foul tasting but ineffective. I went back again a week later and he changed the prescription a bit. A week later nothing had changed.

A strange thing happened when leaving that doctor's office the first time. My right testicle was suddenly so sensitive that with each step, I had a horrible dull pain as it rubbed against my thigh. I almost could not make it to the curb outside to get a taxi. Sitting at home later that night feeling terribly depressed, I tried watching old Jackass episodes to lighten my mood, and I found that laughing caused the same intense pain. It occurred to me that this was a hernia symptom, so I spent some time reading about it. I found what I believed to be the left inguinal canal, explored it a bit, and then went to the right one, where I felt no difference. The surprising thing was that after I did this, I stood up without really thinking about it and started walking around – and experienced no pain! This got me excited enough to go the next day to Huashan hospital to get checked specifically for a hernia.

I saw a general physician who felt around and found nothing. He started telling me the same things most of the others have, and he kept resisting the idea of having an x-ray or CT scan, yet he would not say why (I know now that both of these are ineffective for hernia detection - what I should have asked for was a dynamic ultrasound). My insistence flustered him enough that he called in a urologist to consult. The urologist was no different than the others, ultimately saying that the idea of a hernia in my case was ridiculous because there was nothing palpable. He wound up prescribing levofloxacin for six weeks along with a TCM herbal tablet called Wenglitong Jiaonang. I took the levo for two weeks and felt no improvement.

At the end of August, I saw yet another TCM doctor closer to home and poured out the whole story to him. He gave a little speech about how he was going to be different, and how my pain would be gone in a week after taking these herbs he prescribed, etc. He wanted me to have a digital prostate exam, but I refused - Chinese people seem to have a very different idea of what constitutes significant pain, and thus medical staff here can be a bit rough! Anyway, he pronounced it as 'probably prostatitis' and sent me on my way. It didn't work.

After two weeks week of fennel+fenugreek tea (another combination that has helped some on the boards), I flew to Hong Kong hoping to not only see my regular physician, but be referred to some specialists. I had a dynamic ultrasound which points to several possible causes; here are the findings:

Both of the testicles are of normal size and echogenicity. (Measurements omitted) The echotexture is homogenous although there are small clusters of hyperechoic nodules measuring approximately 0.1cm at the inferior pole of both testes. These are most likely foci of calcification indicating previous inflammation. There is no increased vascularity elicited within either testes.

There is a 0.4cm x 0.2cm epididymal cyst at the head of the right epididymis. The rest of the right epididymis is unremarkable. There is a similar cyst measuring 0.4cm at the head of the left epididymis with a smaller 0.2cm cyst at the tail. Some calcification is noted within the body of the left epididymis which is also midly thickened. However, no increased vascularity is found on colour doppler. The overall appearances may therefore indicate post infective change.

There is no evidence of varicocele in the right scrotum but the veins in the left testis are distended particularly after Valsalva maneuver measuring more than 0.3cm, suggestive of a varicocele.

In addition, there is a small right inguinal hernia elicited on increased intra-abdominal pressure (remember the doctors who ridiculed the idea that I might have a hernia!). The left inguinal orifice is intact.

Both kidneys are of normal size and appearance. (Measurements omitted) There is an echogenic lesion at the left upper pole measuring 1cm without acoustic shadowing which is most likely haemangioma.

Impression:
1. Foci of calcification within inferior pole of both testicles suggestive of previous inflammation/infection.
2. Small bilateral epididymal cysts with mildly thickened left epididymis suggestive of previous epididymitis.
3. Right inguinal hernia
4. Left varicocele
5. Probable angiomyolipoma in the left kidney

A manual prostate check and blood/urine tests turned up nothing. The doctor said he didn't think referral to any specialists was necessary and instead wanted me to try gabapentin. It's been over month since that visit, and I have stopped taking the gabapentin. I wasn't feeling any better with it, and it was causing loads of abdominal pain.