How to cite: Terlecki RP. Making scrotal pain less painful for patients and providers: algorithm plus tips and tricks. Grand Rounds in Urology. October 2025. Accessed January 2026. https://grandroundsinurology.com/making-scrotal-pain-less-painful-for-patients-and-providers-algorithm-plus-tips-and-tricks/
Summary
Ryan Terlecki, MD, FACS, Professor and Vice Chair of Urology, Wake Forest University, Winston-Salem, North Carolina, addresses chronic scrotal pain and offers a structured, reproducible approach to reduce frustration for both patients and providers. Dr. Terlecki emphasizes that much of the difficulty surrounding these visits stems from inconsistent evaluation, poor expectation-setting, and unstructured communication, rather than diagnostic complexity alone.
He begins by acknowledging provider anxiety when managing genital pain complaints. Dr. Terlecki explains that patients often seek validation and fear dismissal, particularly after multiple unsuccessful evaluations. He stresses avoiding assumptions about psychological or medication-seeking behavior and instead focusing on consistent, transparent communication.
Dr. Terlecki suggests using a structured intake questionnaire and management algorithm to provide to patients before the visit. This approach allows clinicians to control the flow of the encounter, identify key historical features, and set expectations early. He outlines critical intake elements, including pain characteristics, urinary and bowel function, orthopedic and neurologic history, associations with ejaculation, hormonal deficiencies, and metabolic conditions.
He reviews common diagnostic pitfalls, emphasizing that prostatitis, varicoceles, and incidental ultrasound findings are often overdiagnosed, while pelvic floor dysfunction and referred pain are frequently overlooked. A stepwise evaluation strategy is presented, incorporating physical examination, uroflow and postvoid residual assessment, laboratory testing, and targeted imaging when indicated.
Management strategies focus on treating identifiable contributors while avoiding unnecessary escalation. Dr. Terlecki discusses medical therapies, selective use of nerve blocks, limited surgical intervention, and early involvement of pelvic floor physical therapy. He emphasizes that a cookbook-style algorithm, multidisciplinary collaboration, and clear expectations can dramatically improve outcomes and satisfaction.
About The 12th Urology Today Conference:
Presented by chair Ryan P. Terlecki, MD, FACS, the 12th Urology Today conference was designed to keep urologists, urologic oncologists, and other healthcare providers educated on the most pertinent issues in urology practices. Areas of focus included urologic oncology, men’s health and reconstruction, female urology, pediatric urology, kidney stones and related conditions, and methods of providing the best care amidst the required logistics of the business side of medicine.
ABOUT THE AUTHOR
Ryan P. Terlecki, MD, FACS, is a reconstructive urologist for Atrium Health Wake Forest Baptist Medical Center, an academic Level 1 trauma center in Winston-Salem, North Carolina. Dr. Terlecki holds the rank of Professor and the title of Vice Chair of Research for the Department of Urology. In addition, Dr. Terlecki is Director of the Men’s Health Clinic, Director of Medical Student Education, and Fellowship Director for Reconstructive Urology. He holds a joint appointment in the Department of Obstetrics and Gynecology.
Dr. Terlecki earned his medical degree from Wayne State University School of Medicine and completed residency in general surgery and urology at Detroit Medical Center. Following his residency, Dr. Terlecki completed two separate fellowships in reconstructive surgery. He completed a fellowship at the University of Colorado’s Denver School of Medicine and at UT Southwestern Medical Center in Dallas, Texas.
Dr. Terlecki’s publications cover multiple areas of trauma and reconstruction and his research is focused primarily on models of wound healing and regeneration in the lower genitourinary system. Dr. Terlecki’s areas of expertise include urethral stricture disease, male sexual dysfunction, male incontinence, Peyronie’s disease, chronic testicular pain, hypogonadism, and infertility. He is a member of the Society of Genitourinary Reconstructive Surgeons (GURS), a member of the American Urological Association (AUA), and past president of the North Carolina Urological Association (NCUA).
