Intratunical bupivacaine and methylprednisolone instillation for scrotal pain after testicular sperm retrieval procedures

Gul K. Talu¹, Tibet Erdogru², Tansel Kaplancan², Mustafa Bahceci³

Asian J Androl 2003 Mar; 5: 65-67             

Keywords: pain; scrotum; sperm retrieval; testis

Abstract

Aim: To investigate the effect of intratunical instillation of bupivacaine and methylprednisolone for scrotal pain, swelling and peritesticular fibrosis due to testicular sperm retrieval procedures. Methods: A total of 65 patients were randomly divided into two groups. In the instillation group (GI), 34 patients were administered 2.5 ml of 0.5 % bupivacaine combined with 10 mg/ml methylprednisolone before closure of the tunica vaginalis. In the control group (GC), 31 patients only received analgesics postoperatively by intramuscular route. The pain (by visual analogue scale, VAS) and duration of pain-free period after surgery between the two groups were evaluated at 2 and 4 h and at days 2 and 7 postoperatively. Results: The mean pain scores were significantly lower in the GI than in the GC group at 2 and 4 h after surgery (P<0.05 and P<0.01, respectively). The mean duration of pain free interval after the procedure was 47.816.9 (12-72) h in GI, which was significantly longer than that in GC [(9.93.6; 4-20) h]. Besides, in the GI, 29 % of patients were completely free from pain and 67 % had no scrotal swelling, but in the GC, all the patients required additional NSAID injection due to pain and only 3 % had no scrotal swelling. Conclusion: This study confirms that direct intratunical instillation of bupivacaine and methylprednisolone around the testis reduces the postoperative pain, scrotal swelling and peritesticular fibrosis.

1 Introduction

Testicular sperm extraction (TESE) and microepidi-dymal sperm aspiration (MESA) have become important sperm harvesting procedures during intracytoplasmic sperm injection (ICSI) procedure in azoospermic males. Severe scrotal pain induced by the manipulation may delay the discharge of the patient from the ambulatory care unit despite conventional analgesic treatment. Also, the scrotal pain and swelling developing due to the surgical intervention (more tunical incisions are required for severe hypospermatogenesis) may continue for 5 to 7 days postoperatively that limits the patients' daily activity and causes significant morbidity at home.

The nerve supply to the testis and the tunica albuginea is derived from the sympathetic autonomic plexus via the 10th and 12th thoracic nerve roots, which are difficult to be interrupted by peripheral regional blockade [1]. Scrotal surgery usually results in moderate to severe scrotal swelling due to inflammation and oedema. The oedema may take a couple of weeks to resolve in spite of systemic anti-inflammatory therapy. Furthermore, peritesticular fibrosis may be observed in patients after even minimal scrotal surgery.

The anti-inflammatory mechanism of corticosteroids is considered to be due to the inhibition of phospholipase A2, which plays an important role in the pain mechanism. Inspired by the anti-inflammatory effect of methyl-prednisolone and the analgesic effect of bupivacaine, we aimed to evaluate the analgesic and anti-inflammatory effect of local instillation of a combination of these drugs into the tunical vaginal space surrounding one or two testicles in patients undergoing uni- or bilateral testicular sperm extraction or epididymal sperm aspiration as a part of the ICSI procedure.

2 Materials and methods

With the approval of the local ethics committee and signing of the informed consent on the part of the subject, a total of 65 azoospermic male patients (34.94.2 years of age) undergoing selective scrotal exploration with uni- or bilateral TESE or MESA were enrolled in this study. Patients having a history of orchioepidydimitis, having previous scrotal surgery or taking relevant drugs in the last six weeks were not included in the study. They were randomly divided into the Instillation Group (GI, 34 cases) receiving installation of 2.5 ml of 0.5 % bupivacaine and 10 mg/mL methylprednisolone around the testicles before closing the tunica vaginalis, and the Control Group (GC, 31 cases) receiving a nonsteroidal anti-inflammatory drug (NSAID), diclofenac 75 mg, postoperatively by the intramuscular route.

Standard general anaesthetic technique with muscle relaxation and intubation was used. All patients had 1m/kg fentanyl citrate during induction with no supplemental analgesics during the procedure. Non-absorbable suture (5/0 prolene) was used for tunica albuginea and tunica vaginalis repair during the TESE procedure, and absorbable suture material (4/0 chromic catgut) for closing the subcutaneous fasciae and skin.

Postoperative pain was evaluated by using a visual analogue pain score (VAS), which is represented by a 10 cm straight line where one end 0 represents no pain and the other end 10, the worst possible pain [2]. The assessment was performed in the immediate postoperative period as soon as the patient could respond to questions and repeated 2 and 4 h later. If there was severe pain after the 4th hour, an additional dose of NSAID was given. Pain free period (in hours) was recorded on day 2 and 7 after operation. Scrotal swelling and wound healing were also examined on these days.

Data were expressed in meanSE. The student's-t test was used for statistical analysis and P<0.05 was considered significant.

3 Results

From the Table 1, it can be seen that the mean pain scores were significantly lower in the GI than in the GC group at the 2nd and 4th h after surgery (P<0.05 and P<0.01, respectively). The mean duration of pain free interval after the procedure was 47.816.9 (12~72) h in GI, which was significantly longer than that in GC (9.93.6; 4~20). Besides, 10 patients (29 %) from GI were completely free from pain and 23 (67 %) had no scrotal swelling; in the GC, all patients required a second injection of NSAID due to pain and 30 (97 %) had scrotal swelling. Neither wound infection nor orchiepidydimitis was seen at 1 to 3 months postoperatively in both groups and no problem in wound healing was observed.

Secondary TESE or MESA procedures were performed in 10 GI and 8 GC patients. No peritunical, peritesticular or periepidydimal fibrosis was observed in all the GI patients, while in the GC there were moderate peritesticular and periepidydimal fibrosis in 4 patients and slight incisional fibrosis in the remaining 4.

Table 1. The mean pain scores after surgery. ^bP<0.05, ^cP<0.01, compared with controls.

4 Discussion

Recently, new approaches for relieving scrotal pain especially after the employment of TESE and MESA procedures have been under investigation [3]. Because these are outpatient procedures, the efficacy of pain management becomes an important determinant in patient confinement [4]. Furthermore, testicular pain might have a negative psychological impact on patient's spouse, who is about to become a candidate for embryo transfer in 48 to 72 h. Other important disabling factors are scrotal swelling and peritesticular and epididymal fibrosis that may develop early or late after scrotal surgery. This fibrosis can lead to chronic scrotal pain and discomfort and may adversely affect further TESE and MESA procedures due to difficulties in dissection.

To provide postsurgical pain relief for a variety of surgical procedures, instillation of analgesic agents directly into the operative side is commonly used [5-8]. Recently this approach has become popular in testicular biopsy procedures using intratunical (tunica vaginalis) bupivacaine [9]. Steroids were mostly used to reduce oedema [10, 11]. Citardi indicated the effectiveness of intrasinusoidal beclomethasone instillation in the treatment of refractory postoperative mucosal oedema [12]. Assimes and Lessard [13] reported that 47 % of the members of The American Society of Maxillofacial Surgeons utilized short-term, high-dose peri-operative corticosteroids to control postoperative inflammation. The most common reason for not using steroids was a perceived lack of literature supporting their effectiveness[10, 13]. Watanuki et al [14] pointed out that intra-operative administration of large dose of steroids was effective not only in reducing pain but also in relieving postoperative pyrexia in patients underwent total hip joint or knee joint replacement. Studies have shown that steroids might delay wound healing, inhibit collagen synthesis and increase the risk of postoperative infection. However, a single administration intraoperatively does not seem to cause these complications.

Intratunical local anaesthetic instillation has been described previously [8]. To our knowledge intratunical corticosteroid instillation has not been used so far in the literature. This study is the first to instill a combination of local anaesthetic and corticosteroid into the tunica vaginalis. Intratunical instillation of the combination significantly decreased the postoperative scrotal pain, scrotal swelling and peritesticular fibrosis and prolonged the postoperative pain-free period with no apparent adverse effects upon wound healing and infection. This study did not compare the effects of bupivacaine alone versus bupivacaine plus methyprednisolone due to limited number of patients.

The skilful technical and scientific assistance of Dr. Benjamin Spencer (Department of Urology, Massachusetts General Hospital) is kindly acknowledged.

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Correspondence to: Dr. Tibet Erdogru, Department of Urology, Akdeniz University Faculty of Medicine, Dumlupinar Bulvari, Kamps 07059, Antalya, Turkey.
Tel: +90-242-227 4480, Fax: +90-242-227 4482
E-mail: terdogru@med.akdeniz.edu.tr
Received 2002-06-17     Accepted 2002-08-16