Ralph Simpson, PT, DPT, OCS, CMPT, CMTPT/DN, LATC
When a patient comes to you with complaints of testicular pain, a pelvic cause is typically one of the first potential causes that come to mind. However, an excellent subjective assessment and applied manual skills may lead you differently.
Recently, a 60-year-old patient came to see me with complaints of pain in his left testicle. I explained I wasn’t a pelvic floor therapist and that I may need to refer him to a therapist who specializes in pelvic health. Nevertheless, please tell me more.
His pain started in September (he consulted with me in late October). He went to his GP, who ordered a lumbopelvic x-ray, which was negative. He was referred to a urologist, who ordered an MRI, which again proved negative for possible causes. At this time, he mentioned to the urologist that he also had left lower anterior abdominal pain between his lower ribs and pelvis. A CT scan was obtained to determine any potential organic cause of testicle pain or quadrant discomfort. After completing all this testing, he came to see me.
“Can you tell me when the pain started?” The patient reported he felt the pain a day after he was splitting firewood. “When was the last time you split wood?” He replied that it had been a full year. In other words, splitting wood was not a usual and ordinary activity for this patient. Normally, I would do a complete lumbar scan exam that includes an assessment of myotomes, dermatomes, several provocative tests, etc. Since his history was lengthy and he had a substantial prior workup, I began with palpation for trigger points that could refer to this area.
Trigger points often result from mechanical overload applied to a muscle or muscles. This overload could come in the form of a large explosive load, an unaccustomed load or exercise, or a light load held for a long time. Splitting firewood uses a fair amount of explosive abdominal muscle contractions, and as a right-handed person, the swing is biased to the left side. It is worth noting that the patient was not a physically fit person.
My thoughts went to muscles involved in swinging a heavy splitting maul that could also refer to the genitals: first to mind came the obturator internus, abdominals, and hip flexors.
The obturator internus had a normal tone and did not produce familiar pain with palpation. Hip internal rotation was within normal limits. Next, I palpated his left oblique abdominals, which were hyperalgesic with trigger points in both internal and external obliques. I proceeded with dry needling; local twitch responses were elicited.
The patient returned in a week, reporting that his left quadrant pain had subsided after some transient needle soreness, but his testicular pain remained. During this session, his left psoas and iliacus muscles were exquisitely tender. I needled both muscles and instructed the patient in a few simple stretches. I asked him to call me in 48 hours with an update. He called three days later and happily shared that his testicle pain had also subsided.
Remember, genital pain doesn’t need to have a sinister organic cause but can come from muscles inside or outside the pelvic floor. A thorough subjective exam combined with the skills learned in the Myopain Seminars dry needling series is one of the most effective treatment approaches to treat soft tissue pain and dysfunction.
Photo by David Lindahl on Unsplash
