4. Data. [Cited 2008.] Available from URL: http://www. medicareaustralia.gov.au 5. Baum M, McCartney M, Thornton H, Bewley S. Breast cancer screening peril. Times On-line. [Cited 27 August 2009.] Available from URL: http://www.timesonline.co.uk 6. National Breast Cancer Centre. Breast Imaging: A Guide for Practice. Camperdown: National Breast Cancer Centre, 2002. 7. Houssami N, Boyages J, Stuart K, Brennan M. Quality of breast imaging reports falls short of recommended standards. Breast 2007; 16: 271–9. 8. Carmichael AR, Bendall S, Lockerbie L, Prescott R, Bates T. The long-term outcome of synchronous bilateral breast cancer is worse than metachronous or unilateral tumours. Eur. J. Surg. Oncol. 2002; 28: 388–91. 9. Tahir M, Osman KA, Shabbir J et al. Preoperative axillary staging in breast cancer-saving time and resources. Breast J. 2008; 14: 369–71. 10. Berg WA. Tailored supplemental screening for breast cancer: what now and what next? AJR Am. J. Roentgenol 2009; 192: 390–9. 11. National Breast and Ovarian Cancer Centre. Advice about Familial Aspects of Breast Cancer and Epithelial Ovarian Cancer: A Guide for Health Professionals. Camperdown: National Breast and Ovarian Cancer Centre, 2006. 12. van den Biggelaar FJ, Nelemans PJ, Flobbe K. Performance of radiog- raphers in mammogram interpretation: a systematic review. Breast 2008; 17: 85–90. 13. Brennan ME, Spillane AJ. The breast physician – an example of specialisation in general practice. MJA 2007; 187: 111–4. Andrew J. Spillane,*† MD, FRACS Meagan E. Brennan,*† FRACGP, FASBP *Northern Clinical School, University of Sydney, Sydney, and †Royal North Shore and Mater Hospitals, North Sydney, NSW, Australia doi: 10.1111/j.1445-2197.2009.05048.x Understanding chronic testicular pain: a psychiatric perspective The management of chronic testicular pain is difficult. Patients in whom a clear organic diagnosis cannot be made may be subjected to a range of surgical treatments of unclear benefit. Many of the clinical features of chronic testicular pain ‘syndrome’ overlap with well- recognized somatoform disorders. Thus, the pain some patients experience may in fact represent underlying psychological conflict that is not surgically remedial. Chronic testicular pain is described as persistent or recurrent episodic pain localized to the testis for at least 3 months. 1 This encompasses a myriad of clinical scenarios: from the patient with unremitting low-grade testicular ache, to episodes of acute scrotal pain with pain-free intervening periods. The main organic causes of scrotal pain that must be considered in each case include infection, testicular torsion and malignancy. Most acute organic causes can be excluded by a thorough history and physical examination, supple- mented where indicated by urine and urethral cultures or PCR (Poly- merase Chain Reaction) and scrotal ultrasonography. However, finding an organic diagnosis for a patient with chronic pain is more difficult. Despite modern advances in diagnostic evaluation, these patients typically undergo more than four procedures each, 3 and no cause is found in 25%. 1 Invasive treatment options have included transrectal ultrasound- guided pelvic plexus block, pulsed radiofrequency, epididymec- tomy, orchidectomy and testicular denervation. 2,4 Evidence for their use is limited to small case series, and their efficacies vary widely. Orchidectomy, previously seen as a last resort, has a reported efficacy of 20–75%. 1,3,5 Testicular denervation has an efficacy of 71–96%, 6,7 and one large series of 79 patients demonstrated durable relief in 71%. 8 However, almost 30% of patients still underwent an unnecessary mutilating procedure. Recent guidelines suggest early involvement of a multidisci- plinary pain team. 2,9 Its role includes initial pain management and further evaluation with procedures such as diagnostic nerve blocks. Medical pain management is first attempted using trials of antibiot- ics, anti-inflammatories, low-dose antidepressants, anticonvulsants, membrane-stabilizing agents and opiates 2 . They are complemented by transcutaneous electrical nerve stimulation, lumbar sympathetic blocks or repeated phentolamine infusions, 2 and other treatments, such as rehabilitative physiotherapy for pelvic floor musculature. 9 The psychiatric considerations reported in most articles about testicular pain have focused on the assessment and treatment of concomitant depression, rather than on the aetiology of the pain. Yet in one study of 48 men, 56% met criteria for a somatoform disorder, and 27% met criteria for major depression. 10 This suggests that the psychological contribution to such presentations may be more sig- nificant than previously identified. Somatoform disorders are a con- troversial collection of psychiatric disorders related to somatization. Somatization is the tendency to communicate psychological distress as somatic and medically unexplained symptoms. There are seven somatoform disorders described in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV, Table 1). 11 Their common Table 1 Diagnostic and Statistical Manual of Mental Disorders (DSM IV) criteria for somatoform disorder Criteria for pain disorder (1) Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention (2) The pain causes clinically significant distress or impairment in social, occupational or other important areas of functioning (3) Psychological factors are judged to have an important role in the onset, severity, exacerbation or maintenance of pain. (4) The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering). (5) The pain is not better accounted for by a mood, anxiety or psychotic disorder. Code as follows: Pain disorder associated with psychological factors. Pain disorder associated with both psychological factors and a general medical condition. DSM IV details the features required for diagnosis of psychiatric disorders. All criteria for pain disorder must be fulfilled for a positive diagnosis. 676 Perspectives © 2009 The Authors Journal compilation © 2009 Royal Australasian College of Surgeons