Chronic Testicular Pain: Causes and Treatment

A testicular mass that can be felt by hand is almost always painless. That is the fact that kills people. A testicle that only hurts, with no lump at all, is almost never dangerous. It is just miserable and poorly understood. That paradox, harmless things that hurt and deadly things that do not, sits at the center of this conversation between host and urologist Dr. Kelly Casperson and her guest, Dr. Susan McDonald, a urologist who specializes in male reconstruction and in the chronic pelvic and testicular pain most doctors would rather not treat.

Pain with no obvious cause shows up constantly in urology clinics. McDonald puts a number on it: roughly 5% of all urologic consultations, about one in twenty visits, is driven by testicle or pelvic pain (04:52). That is a lot of appointments for a problem most training programs barely cover. McDonald argues the avoidance is partly structural and partly psychological. Surgeons, she says, are drawn to the field because they like problems with clean endings.

"Surgeons become surgeons because they're people who like a problem, a surgery, and a better patient. Like, a discrete solution." Dr. Susan McDonald, [05:45]

Chronic pain does not offer that. It is not a kidney stone McDonald can remove in an afternoon and watch a patient walk out relieved. It lingers, it resists imaging, and it tests a surgeon's entire professional identity.

What the Scan Cannot See

McDonald's father ran a mechanic shop, and she uses that memory to explain why a normal scan does not mean nothing is wrong. An ultrasound, a CT scan, and an MRI are all pictures. Popping the hood of a car that will not start and taking a photo tells a mechanic nothing about why the engine is dead (07:35). The same logic applies to a testicle. A normal ultrasound rules out a mass. It does not rule out pain, because pain is a function, not a structure, and medicine does not have a functional scan for it. "Testicular cancer, like a mass, is typically painless, almost always painless. That's what will kill you. Testicular pain, what you feel, is really annoying, but it's not deadly," McDonald says (08:14).

What happens next is a kind of institutional shortcut. Doctors need a billing code, so patients with completely normal exams routinely get labeled with epididymal orchitis, medical language for a testicle infection that is not actually present (10:10). McDonald calls these labels heavy bricks.

"I call it heavy bricks in a backpack because people start walking around with heavy bricks in a backpack because some clinician with, you know, power and expertise gave them a brick." Dr. Susan McDonald, [11:08]

Nobody tells patients they are allowed to set a brick down once a diagnosis stops fitting. The label sticks, the backpack gets heavier, and the patient starts to look, to every doctor after that, like someone with a chronic infection rather than someone whose pain was never properly investigated.

Part of the fix, when it works, is strikingly concrete. In fellowship, McDonald learned a procedure called microsurgical denervation of the spermatic cord, which uses an operating microscope to strip the nerve-carrying structures off the cord that runs from the abdomen to the testicle, leaving the testicle unable to sense pain (19:36). Published studies define success as a 50% reduction in pain. McDonald's early patients, people who had lived with pain rated seven out of ten for a decade, often became completely pain-free (20:03). She is careful to note that the surgery only works in carefully chosen patients, and that even those who land at the 50% mark generally say, without hesitation, that they would do it again.

The other piece of McDonald's practice sits at the overlap of three specialties: sexual medicine, voiding problems, and testicle pain. In the middle of that overlap is pelvic floor dysfunction, a condition where the muscles supporting the pelvis become too tense rather than too weak. The standard advice for pelvic problems, Kegel exercises, actually makes this worse, because Kegels tighten muscles that are already overtight (22:38). The fix is relaxation and pelvic floor physical therapy, a resource McDonald says she sought out and built relationships with before she even took a faculty job.

When the Doctor Becomes the Patient

Midway through the conversation, the subject changes the way life sometimes does without warning. Eight years into practice, at what she calls the top of her game, McDonald was diagnosed with stage 4 breast cancer. It was de novo, meaning the cancer was already stage 4 at the moment of diagnosis rather than progressing there from an earlier stage, it was bilateral, and it arrived with no family history (32:04). Only about 7% of breast cancer patients are diagnosed stage 4 de novo, and the share is far smaller among premenopausal women in their thirties and forties, McDonald's group (32:55).

She had missed the mass herself. She had also, without noticing, trained her own body not to feel hungry while experimenting with intermittent fasting. After her diagnosis, it took six months of treatment before real hunger returned (37:04). In hindsight, the vanishing appetite was an early warning sign she had mistaken for a lifestyle win. The injury that finally sent her for scans, a fractured shoulder blade, had been nagging her for a year by her husband's account, though she only remembered a few weeks of it (39:13). McDonald connects all of this to a habit she says is built into surgical training.

"As surgeons, we are pathologically conditioned to ignore our bodies." Dr. Susan McDonald, [38:44]

She describes learning, over years of residency, how to carb-load before a long surgery, bank sleep ahead of a hard week, and use caffeine to push through exhaustion. The same skills that make a surgeon reliable in the operating room are the ones that let a serious illness go unnoticed for a year.

Recovery forced a second education, this one in the business of medicine. As an academic surgeon, McDonald could not sustain a full workweek during chemotherapy, so she asked to drop below 50% time. Her hospital employer never gave her a clear definition of what full-time meant for a surgeon in the first place, and when she asked what would happen if she worked less than half-time, human resources told her she would lose employer-sponsored insurance and would need to buy COBRA, continuation coverage purchased directly from the plan, at a cost of $24,000 a year for up to eighteen months (51:03). She hired a lawyer. The hospital held its position.

"I achieved all my dreams, and none of it mattered in the end." Dr. Susan McDonald, [52:15]

She left academic medicine and now works as chief medical officer at VidScrip, a company that makes short patient-education videos, while building a speaking career on cancer resilience and pelvic pain awareness.

The conversation closes on smaller, stranger victories. McDonald's palliative care doctor, Christina Newport, suggested tart cherry juice for the night sweats brought on by hormone-suppressing treatment. McDonald tried it out of desperation and found that a single eight-ounce glass, even a cheaper tart cherry lemonade bought in a pinch at an organic grocer in a resort area after she could not find tart cherry juice at the airport, cut her hot flashes by roughly 80% (57:33). She does not know the mechanism. She now drinks it daily in a morning smoothie and plans to plant tart cherry trees on her property.

The two threads of the episode, testicle pain nobody wants to treat and a cancer diagnosis nobody wanted to believe, share a spine. Both are stories about bodies sending signals that the systems around them are built to miss: a scan that cannot show pain, a schedule that cannot show exhaustion, a billing code that cannot show uncertainty. McDonald's advice, for patients and for herself, is the same in both cases. Notice the signal before it hardens into a diagnosis, or a loss, that cannot be undone.