Post-vasectomy pain syndrome

Post-vasectomy pain syndrome (PVPS) is a chronic and sometimes debilitating genital pain condition that may develop immediately or several years after vasectomy.[1][2][3] Because this condition is a syndrome, there is no single treatment method, therefore efforts focus on mitigating/relieving the individual patient's specific pain.[1][2][4][5] When pain in the epididymides is the primary symptom, post-vasectomy pain syndrome is often described as congestive epididymitis.

Symptoms
  • Persistent pain in the genitalia and/or genital area(s).
  • Groin pain upon physical exertion.
  • Pain when achieving an erection and/or engaging in sexual intercourse.
  • Pain upon ejaculation.
  • Loss of erectile function

Any of the aforementioned pain conditions/syndromes can persist for years after vasectomy and affect as many as one in three vasectomized men.[6][7] The range of PVPS pain can be mild/annoying to the less-likely extreme debilitating pain experienced by a smaller number of sufferers in this group. There is a continuum of pain severity between these two extremes. Pain is thought to be caused by any of the following, either singularly or in combination: testicular backpressure, overfull epididymides, chronic inflammation, fibrosis, sperm granulomas, and nerve entrapment. Pain can be present continuously in the form of orchialgia and/or congestive epididymitis or it can be situational, such as pain during intercourse, ejaculation or physical exertion.

Mechanisms of pain

There is a noticeable enlargement of the epididymides in vasectomized men.[8][9] This is probably due to increased backpressure within the vas deferens on the testicular side following its blockage by vasectomy. The efferent ducts and seminiferous tubules of the testes are also affected by backpressure, leading to an increase in area and thickness.[10] Backpressure from blockage of the vas deferens causes a rupture in the epididymis, called an "epididymal blowout", in 50% of vasectomy patients.[11] Sperm sometimes leak from the vas deferens of vasectomized men, forming lesions in the scrotum known as sperm granulomas. Some sperm granulomas can be painful.[12][13] The presence of a sperm granuloma at the vasectomy site prevents epididymal pressure build-up, perforation, and the formation of an epididymal sperm granuloma. It thus lessens the likelihood of epididymal discomfort.[11]

As part of the reaction of the body to the surgical wounds of vasectomy, the body produces hard scar-like tissue. Clamping the vas deferens can produce muscle disruption and fibrosis.[14] As the diameter of the vas lumen is less than the thickness of the wall, the thick muscle layers can easily become disrupted, leading to sperm accumulation and extravasation. Cysts often form from the fluid that spreads between the muscle layers.[14]

Nerves can become trapped in the fibrous tissue caused by vasectomy. This pain is often heightened during sexual intercourse and ejaculation because, with arousal and ejaculation, muscles elevate the testis. There are several nerves that run parallel to the vas deferens that may be cut or damaged during vasectomy.[15]

One study found that the vas deferens exhibits two periodic forms of electrical activity on an electrovasogram, slow pacesetter potentials and fast action potentials. In vasectomized men, the pacesetter potentials on the testicular side exhibit an irregular rhythm.[10]

One study using ultrasound found that the epididymides of patients suffering from post-vasectomy pain syndrome were enlarged and full of cystic growths.[16]

Treatment

Treatment depends on the proximate cause. In one study, it was reported that 9 of 13 men who underwent vasectomy reversal in an attempt to relieve post-vasectomy pain syndrome became pain-free, though the followup was only one month in some cases.[2] Another study found that 24 of 32 men had relief after vasectomy reversal.[17]

Nerve entrapment is treated with surgery to free the nerve from the scar tissue, or to cut the nerve.[15] One study reported that denervation of the spermatic cord provided complete relief at the first follow-up visit in 13 of 17 cases, and that the other four patients reported improvement.[7] As nerves may regrow, long-term studies are needed.

One study found that epididymectomy provided relief for 50% of patients with post-vasectomy pain syndrome.[18]

Orchiectomy is recommended usually only after other surgeries have failed.[18]

Incidence

A retrospective postal survey of 396 men found that 4% had significant genital pain for more than one year that required surgical intervention.[7]

Another study contacted 470 vasectomy patients and received 182 responses, finding that 18.7% of respondents experienced chronic genital pain with 2.2% of respondents experiencing pain that adversely affected quality of life.[19]

The most robust study of post-vasectomy pain, according to the American Urology Association's Vasectomy Guidelines 2012 (amended 2015)[20] found a rate of 14.7% reported new-onset scrotal pain at 7 months after vasectomy with 0.9% describing the pain as "quite severe and noticeably affecting their quality of life".[21]

An investigation of peer-reviewed articles published in March 2020 examined 559 articles, performed meta-analysis on 25 separate datasets, and concluded that the incidence of post-vasectomy pain syndrome is 5% (95% CI 3% to 8%) with similar incidence of PVPS for both the scalpel and the no-scalpel technique.[22]

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References
  1. Potts JM (2008). "Post Vasectomy Pain Syndrome". Genitourinary Pain And Inflammation. Current Clinical Urology. Humana Press. pp. 201–209. doi:10.1007/978-1-60327-126-4_13. ISBN 978-1-58829-816-4.
  2. Nangia AK, Myles JL, Thomas AJ Jr (2000). "Vasectomy reversal for the post-vasectomy pain syndrome: a clinical and histological evaluation". J. Urol. 164 (6): 1939–42. doi:10.1016/S0022-5347(05)66923-6. PMID 11061886.
  3. Christiansen C, Sandlow J (2003). "Testicular Pain Following Vasectomy: A Review of Postvasectomy Pain Syndrome". Journal of Andrology. 24 (3): 293–8. doi:10.1002/j.1939-4640.2003.tb02675.x. PMID 12721203.
  4. Manikandan R, Srirangam SJ, Pearson E, Collins GN (2004). "Early and late morbidity after vasectomy: a comparison of chronic scrotal pain at 1 and 10 years". BJU International. 93 (4): 93, 571–574. doi:10.1111/j.1464-410X.2003.04663.x. PMID 15008732.
  5. Awsare NS, Krishnan J, Boustead GB, Hanbury DC, McNicholas TA (2005). "Complications of vasectomy". Ann R Coll Surg Engl. 87 (6): 87: 406–410. doi:10.1308/003588405X71054. PMC 1964127. PMID 16263006.
  6. McMahon A, Buckley J, Taylor A, Lloyd S, Deane R, Kirk D (1992). "Chronic testicular pain following vasectomy". British Journal of Urology. 69 (2): 188–191. doi:10.1111/j.1464-410X.1992.tb15494.x. PMID 1537032.
  7. Ahmed I, Rasheed S, White C, Shaikh N (1997). "The incidence of post-vasectomy chronic testicular pain and the role of nerve stripping (denervation) of the spermatic cord in its management". British Journal of Urology. 79 (2): 269–270. doi:10.1046/j.1464-410x.1997.32221.x. PMID 9052481.
  8. Jarvis LJ, Dubbins PA (1989). "Changes in the epididymis after vasectomy: sonographic findings". AJR. American Journal of Roentgenology. 152 (3): 531–4. doi:10.2214/ajr.152.3.531. PMID 2644777.
  9. Reddy NM, Gerscovich EO, Jain KA, Le-Petross HT, Brock JM (October 2004). "Vasectomy-related changes on sonographic examination of the scrotum". J Clin Ultrasound. 32 (8): 394–8. doi:10.1002/jcu.20058. PMID 15372447.
  10. Shafik A (1996). "Electrovasogram in normal and vasectomized men and patients with obstructive azoospermia and absent vas deferens". Archives of Andrology. 36 (1): 67–79. doi:10.3109/01485019608987884. PMID 8824668.
  11. Shapiro EI, Silber SJ (November 1979). "Open-ended vasectomy, sperm granuloma, and postvasectomy orchialgia". Fertil. Steril. 32 (5): 546–50. doi:10.1016/S0015-0282(16)44357-8. PMID 499585.
  12. Schmidt S (1976). "Spermatic granuloma: an often painful lesion". Fertility and Sterility. 31 (2): 178–81. doi:10.1016/S0015-0282(16)43819-7. PMID 761679.
  13. Shapiro, Edward I.; Silber, Sherman J. (November 1979). "Open-Ended Vasectomy, Sperm Granuloma, and Postvasectomy Orchialgia". Fertility and Sterility. 32 (5): 546–550. doi:10.1016/S0015-0282(16)44357-8.
  14. Shandling B, Janik J (1981). "The vulnerability of the vas deferens". Journal of Pediatric Surgery. 16 (4): 461–464. doi:10.1016/S0022-3468(81)80007-3. PMID 7277139.
  15. Pabst R, Martin O, Lippert H (1979). "Is the low fertility rate after vasovasostomy caused by nerve resection during vasectomy?". Fertility and Sterility. 31 (3): 316–320. doi:10.1016/S0015-0282(16)43881-1. PMID 437166.
  16. Selikowitz SM, Schned AR (1985). "A late post-vasectomy syndrome". The Journal of Urology. 134 (3): 494–7. doi:10.1016/S0022-5347(17)47256-9. PMID 4032545.
  17. Myers SA, Mershon CE, Fuchs EF (1997). "Vasectomy reversal for treatment of the post-vasectomy pain syndrome". J. Urol. 157 (2): 518–520. doi:10.1016/S0022-5347(01)65191-7. PMID 8996346.
  18. Chen TF, Ball RY (1991). "Epididymectomy for post-vasectomy pain: histological review". Br. J. Urol. 68 (4): 407–413. doi:10.1111/j.1464-410X.1991.tb15362.x. PMID 1933163.
  19. Choe J, Kirkemo A (1996). "Questionnaire-based outcomes study of nononcological post-vasectomy complications". The Journal of Urology. 155 (4): 1284–1286. doi:10.1016/S0022-5347(01)66244-X. PMID 8632554.
  20. The American Urology association Vasectomy guidelines 2012
  21. Leslie TA; Illing RO; Cranston DW; et al. (2007). "The incidence of chronic scrotal pain after vasectomy: a prospective audit". BJU Int. 100 (6): 1330–3. doi:10.1111/j.1464-410X.2007.07128.x. PMID 17850378.
  22. Auyeung, Austin B.; Almejally, Anas; Alsaggar, Fahad; Doyle, Frank (January 2020). "Incidence of Post-Vasectomy Pain: Systematic Review and Meta-Analysis". International Journal of Environmental Research and Public Health. 17 (5): 1788. doi:10.3390/ijerph17051788.
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