Introduction Orchialgia is an uncommon pain syndrome of the scrotum, nonetheless complicated to treat. When all conservative methods have failed, one can consider invasive treatments as vasovasostomy, epididymectomy, inguinal hemicastration or microsurgical denervation of the spermatic cord. The aim of this study was to investigate I: the effectiveness the aforementioned modalities and II: a possible relationship with the preoperatively performed scrotal ultrasound and the results of the histopathological investigations. Methods 16 patients who were operated because of orchialgia between 2000 and 2010 in our university hospital were included. We recorded age, affected side, previous scrotal surgery, ultrasound findings and the results of the histopathological examinations. Patients were interviewed by telephone survey whether their pain had resolved, improved or persevered. If we could not contact by phone, the data from the files were used. Results Fourteen out of sixteen patients could be reached by telephone. The average age at the time of surgery was 44 years (range 21 to 77). Mean follow-up was 55 months (range 1-135). Eight out of the sixteen patients had an epididymectomy; five (63%) had a subsequent inguinal hemicastration. Over all eleven men had an inguinal hemicastration; two out of sixteen men had a vasovastomy. Of the eight men that underwent an epididymectomie, six (75%) had persisting pain while the remaining two (25%) experienced some improvement. Eight out of the eleven men (73%) who underwent inguinal hemicastration experienced complete relief of pain, one (9%) experienced some improvement and two (18%) had enduring pain. After their vasovasostomy, both men had complete pain relief. Conclusion Inguinal hemicastration following unsuccessful conservative treatments in patients with orchialgia gives good results in three quarters of the cases. The same holds for vasovasostomy in patients with the post vasectomy pain syndrome. Epididymectomy, however, gives poor results.