I learned something today. Something really important. About how to stick to your guns, how use your gut. About what it really means to be a doctor. And, what’s funny is that I didn’t have to cure a man of cancer to learn this, but simply rid him of pain.
A tech engineer, he hailed from South America and moved to Miami. His scrotal pain started there several years ago. Nagging, low grade, left sided pain. He was treated there by several urologists, but the pain continued. It had gotten to the point in which it became a constant bother, affecting his daily activity, sexual relationships, sleep and work performance. He even turned down job interviews at high profile tech companies to avoid travelling in pain. When he moved to California, “the first thing I did was to come to see you, Dr. Turek.”
Typical Male Behavior
Pain is complicated. Always has been, always will be. Especially if it’s chronic, lasting more than 3 months. Pain in reproductive age men adds yet another layer of complexity, as pain is one of three triggers for young men to seek care. The others are bleeding and if something is life threatening. Without these triggers, many men are content to go on their merry way in life and just as happy to avoid seeing doctors.
My Codex for Pain
As a doctor who performs surgery for a living, I have a set of surgical principles I follow for treating pain in young men. Here they are:
- Try not to take things out.
- Remember that since not everything is a nail, you’ll need more than a hammer.
- Know your anatomy!
- Realize that surgery works best for pain that is anatomical (e.g. hernia or varicocele).
- Realize that not all pain is anatomical (e.g. inflammation).
- Recall that anatomical pain tends to be consistent and not migratory.
- Make sure that if you pull the trigger on surgery, it will actually help the patient.
- Listen before you act. You must believe that patients know their bodies better than you do.
When I met him, it was clear that the pain was very complex and woven into all aspects of his life. Because it didn’t meet my principles for surgical cure, I treated him “medically” for a good year, with anti-inflammatories, neuromodulators and temporary blocks. I also enlisted the help of a team of specialists, including therapists, acupuncturists, pain management gurus and pelvic health providers. I also listened. At times, he was better and at other times he was the same. But, through all of this, I came to know him better, and two things became apparent: (a) that despite any Xray, ultrasound or exam evidence of an anatomical problem, he appeared to have anatomical pain, and (b) there was no secondary gain for him to have pain. He was real and it was real, but we couldn’t define “it.”
So, I pulled the trigger and performed “exploratory” surgery. Lo and behold, he had a rare, benign, anatomical cause of testis pain that escaped the radar of all providers and imaging studies. It was removed and he is now fine, even smiling in the recovery room after the procedure. Here’s to following golden rules in life! In the words of Raheel Farooq: “The intelligent have plans; the wise have principles.”