There is a well-recognized entity that can present among a small number of men after vasectomy that has become known as a post vasectomy pain syndrome. This syndrome can begin immediately after the vasectomy or many months or even years after the vasectomy has been completed. The frequency of this problem varies amongst given practitioners. Some studies reports as high as one third of men after vasectomy have some type of lingering discomfort. Other studies report that the frequency of post vasectomy pain is one case in thousands. Because of the wide variations in the incidence of post vasectomy pain in the practices of different vasectomy surgeons, it is important that each surgeon give their patients an accurate account of what the risks of post vasectomy pain syndrome would be in their specific practice. Some of the speculative causes of post vasectomy pain are:
- A "rough" surgery where significant amounts of tissue and nerves have been disrupted and/ or tied that have caused lingering irritation of the nerves. While this may be a frequent cause of post vasectomy pain syndrome one can imagine that it would be less common in the patients of experienced vasectomists.
Treatment Option: In regards to a rough surgery, this would likely be the most difficult to treat and to identify as a cause of pain. Possible treatments could include exploration of the area to remove scarred or inflamed tissue, manual manipulation or stimulation of the painful area, or just allowing time to heal.
- A sperm granuloma could develop post vasectomy that becomes inflamed and aggravates the surrounding nerve endings. The sperm granuloma is a build up of extravisated sperm at the end of the cut vas tube end. The reason why a sperm granuloma may develop is not well understood.
Treatment Option: In the case of a sperm granuloma, injecting it with steroids or actually cutting out the inflamed granuloma has been found effective in the past. Surgery should always be viewed as a last resort.
- Inflammation and swelling of the surrounding nerves called neuroma could develop. This could cause intermittent or constant pain. In addition, Dr. Pollock has also had a high rate of treatment success using an air pressure powered jet injector, called the madajet.
Treatment Option: Nerve blocks i.e. injection of various anesthetic solutions have been tried. So have injections of steroids, or excision of the neuroma.
- A congestive state in the epididymis from back pressure to the epididymis and testes from performing a closed-ended vasectomy. Some authors believe that by blocking both the upper and lower cut ends of the vas tube the normal passage of sperm from the penis and away from the epididymis and testes causes a build up of pressure and ensuing pain. Studies have shown that this situation can be prevented to a large degree by performing an open-ended vasectomy. In carrying out an open-ended vasectomy, the lower or testicular end of the cut vas is left open, thereby allowing the sperm to drain out of the tube preventing a build up of pressure.
Treatment Option: In regards to pain resulting from a congestive state from a closed ended vasectomy, converting that vasectomy to an open ended vasectomy or considering a vasectomy reversal have been identified as being effective. Dr. Pollock has had excellent results in relieving pain doing the conversion of closed-ended vasectomy to open-ended vasectomy. This is also a much simpler procedure than carrying out a vasectomy reversal.
- A vasectomy carried out too close to the epididymis can cause chronic pain and inflammation at the epididymis.
Treatment Option: Surgery carried out too close to the epididymis causing chronic epididymitis may respond to medications or require an epididymectomy.
- Some speculate that post vasectomy pain could be mediated by an immune reaction. It is known that antibodies to sperm are produced by the body after vasectomy. It is possible that these antibodies can react with testicular epididymal and or scrotal tissue to cause an inflammatory reaction.
Treatment Option: Some advocate the use of a steroidal anti-inflammatory like Prednisone for 1-2 weeks. This treatment may be particularly helpful in treating an antibody/immune mediated cause of the pain. Hormone treatment with testosterone, +/- progesterone may also be effective in suppressing the production of the antigen (sperm) and therefore may help in treating an antibody-mediated immune reaction.
- Shorter term causes of post vasectomy pain include infection and post operative inflammation which tend to resolve with the appropriate medications and rarely persist long enough to fall into the category of becoming chronic.
Treatment Option: Regarding treatment of shorter post vasectomy pain like post operative inflammation or infection, the use of anti-inflammatories for inflammation and appropriate antibiotics for infection have been shown to be effective in dealing with this type of pain.
- An undiagnosed depression that is totally unrelated to the vasectomy. In these cases the vasectomy and the perceptions of continued pain become a somatization reaction i.e a physical expression of psychological pain. Depression can also be caused by post vasectomy pain syndrome. The depression can keep the pain perceptions ongoing even once the original cause of the pain is long gone.
Treatment Option: In case of depression and somatization, counseling and anti-depressant medications can be very effective.
- While there is no evidence that vasectomy causes prostatitis, new cases of prostatitis have been infrequently described post vasectomy. So prostatitis should be ruled out by digital exam and possibly scope.
Treatment Option: Prostatitis can be treated with antibiotics like Cipro, sometimes requiring many weeks of therapy.
Potential treatments for post vasectomy pain include:
Getting a second or third opinion from different practitioners with an expertise in treating post vasectomy pain is always advisable.
Time, sometimes 1-2 years, without doing anything at all, may heal the problem.
Some investigations that may help sort out the cause of post vasectomy pain include:- scrotal ultrasound
- semen culture and sensitivity and gram stain
- anti-sperm antibodies
- surgical scrotal exploration
- Opening the testicular end of the vas
- a careful physical examination of the scrotal contents by a qualified physician
- a careful psychological history to rule out depression.
- Cystoscopy - scoping the urethra with observation of the prostate gland and bladder.
Dr. Pollock has a special interest in the diagnosis and treatment of post vasectomy pain syndrome. He provides second opinions for patients throughout Canada. He is currently offering treatments such as converting closed-ended vasectomies to open-ended. Anyone with questions is invited to contact him. drneil@pollockclinics.com
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