Overview

Vasectomy is a frequently performed procedure for effective permanent male contraception.¹ Uncommonly, some patients may experience chronic pain for more than 3 months, which is classed as post-vasectomy pain syndrome (PVPS).^1,2 It may present in various degrees of severity and manner, with some patients having a decreased quality of life.² There are different symptoms, ways of evaluating PVPS and treatment options which will dictate the long-term outcome and recovery for this complication.²

What is post-vasectomy pain syndrome (PVPS)?

Vasectomy is a surgical procedure for people with male reproductive organs to permanently become sterile to prevent pregnancy.¹ Normally, sperm is produced in the testes, then passes along a tube called the vas deferens, which then allows different components of the seminal fluid to later join together and make semen.³ Semen then reaches the penis and is released via ejaculation. When performing a vasectomy, the vas deferens needs to be sealed.⁴ There can be several ways to prevent the sperm from entering the urethra, with techniques to cut, clip or seal.⁴ 2-4 months after the operation, a semen analysis needs to be done to ensure there is no sperm or only rare non-motile sperm.⁵ Otherwise, a repeated analysis will need to be done 6 months after the vasectomy.⁵

A minority subset of patients will suffer from chronic pain in their testicles for more than 3 months.² This is called post-vasectomy pain syndrome (PVPS), and this may occur in around 1-6%, but has been reported up to 20%.⁶ The pain may vary in severity and duration, with some being a sharp pain that affects normal day-to-day activities, whilst others may feel dull, sporadic aches.^2,7 Below are the different presentations you may find:^2,7

• Pain or aches in one (unilateral) or both testicles (bilateral)
• Constant or periodic pain
• Pain when ejaculating
• Pain during physical activity
• Persistent pain in the scrotum  
• Pain during or after sexual intercourse
• Swelling or fullness of the vas deferens

Although currently there is not a comprehensive understanding of why PVPS occurs, some possible causes include damage, scarring or inflammation in the vessels, nerves and ducts surrounding or attached to the testes.² It may also be due to the compression of the nerves or back pressure from the produced sperm that are unable to be ejaculated.²

How is PVPS diagnosed?

It is important in the diagnostic process to eliminate the possibility of other disorders, so that the underlying complication is not masked by the apparent painful symptoms of assumed PVPS.2 Some disorders with similar symptoms that can be mistaken as PVPS include:²

• Infections
• Swelling in the scrotum from a hydrocele, with fluid-filled sacs, or a varicocele, with swollen veins
• Testicular torsion – the rotation of the testicle and the surrounding tissues
• Pain from damaged or malfunctioning nerves
• Inflammation in the prostate
• Psychogenic causes

To correctly diagnose PVPS, some further tests may need to be done.² Physical examinations and analyses of the urine, semen and blood can bring attention to infections if present.² An ultrasound scan uses a probe that produces sound waves on the skin.^2,8 The sound waves will bounce back at different patterns depending on the structures inside the body and will be picked up by the probe to create an image on the computer.⁸ This may be used on the scrotum to allow healthcare professionals to see if there are any abnormalities unrelated to the vasectomy.² If more information is needed or disorders related to compression or damage of the nerves are suspected, Magnetic Resonance Imaging (MRI) can be done.² It uses a combination of radio waves and a strong magnet to produce detailed images inside the body.⁹

Therefore, to safely and accurately diagnose PVPS, a few months of clinical and physical examinations may be needed.²

What is the management for PVPS?

Non-invasive treatments

It is best to begin with non-invasive approaches and alternate or escalate treatment plans if symptoms still persist.² Some treatments can be provided as the chronic pain is being evaluated or at early stages of diagnosis, such as psychosocial therapy, physiotherapy, particularly pelvic floor exercises, and acupuncture, which may allow a more holistic improvement in overall well-being.² Life-style changes can also be made, such as supportive underwear and using ice or heat packs to reduce discomfort.¹⁰

Oral medication, as another form of non-invasive treatment, may also be suggested.² Patients will be given non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and meloxicam, for a duration of 2-4 weeks to help reduce the level of pain experienced.^7,11 If the pain does not subside after the usage of NSAIDs, second-line treatment of tricyclic antidepressants may be prescribed, which may be able to alleviate pain more specifically in the nerves.² They are thought to work by allowing for more chemicals related to mood and emotion, like serotonin and norepinephrine, to be available in the nervous system, which seems to correlate with the feeling of pain.¹² Another type of medication is anticonvulsants, such as gabapentin, which, although they are typically used for treating epilepsy, can relieve pain.^2,13 The exact mechanism of action is unclear, but it has been suggested to dampen the firing of pain messages in the nervous system and spinal cord.^14,15

More advanced treatments

Non-invasive treatments may provide minimal pain relief and cannot be used for long-term use.² If a small yellow mass is noticeable by touch around the site of vasectomy, that may be due to leaked sperm from the vas deferens, called a sperm granuloma.¹⁶ This can be solved by the removal or excision of the lump.² Spermatic cord block is a minimally invasive procedure that provides short-term reduction of pain by injecting an anaesthetic called lidocaine.² Successful pain relief allows deduction of a neuropathic cause for PVPS, and signals for a subsequent procedure called micro-denervation of the spermatic cord (MDSC).2 This is also known as cord stripping, where the nerves within the spermatic cord are cut, and therefore, the signals of pain cannot be fired.2 If the pain is centralised in the epididymis, the area at the back of the testicle that stores sperm, its removal, an epididymectomy, can help alleviate the pain.² It has been shown in a study that a combination of this procedure with injections of a type of sugar, hyaluronic acid, and a thickening agent, carboxymethyl cellulose, provides better reduction of pain.^2,17 Alternatively, the previously performed vasectomy can be reversed, a vasovasostomy, which directly removes pain caused by the back pressure from sperm that could not travel through the vas deferens.^2. Though ultimately would make the initial vasectomy ineffective. The last line of treatment would be the removal of one or both testicles, called an orchiectomy.² It may relieve pain, but it will also carry undesirable effects from hormonal changes.^2,18

What is the long-term outlook for patients with PVPS?

Even though PVPS may only occur in a small group of patients who have undergone vasectomies, understandably, it may bring discomfort and a decrease in quality of life with various degrees of severity.² Starting with conservative approaches to eliminate the pain allows safer outcomes to reduce risks associated with surgeries.²

Positive results from surgical treatments have often been demonstrated.2 For example, MDSC procedures have been shown to be successful in studies for PVPS pain relief in over 70% of patients.^2,19,20 Around 80-90% of patients were shown to have a reduced level of pain with a vasovasostomy in many studies.^2,21

However, it is important to remember that successful pain relief is not guaranteed with surgical procedures, which is why it is important to correctly diagnose the disorder and start the treatment plan with non-invasive therapies.² There may be cases where the pain continues or gets worse; therefore, it is crucial that patients are aware of the risks and potential trajectories after these operations.²

Summary

Although uncommon, chronic pain experienced in patients suffering from PVPS can negatively affect their lives and daily activities. Fortunately, there have been various approaches for effective pain relief. To get the most optimal and well-sustained outcomes, it is important to obtain a correct diagnosis, as it helps suggest the most appropriate form of treatment to reduce pain. PVPS is often treatable, so patients are encouraged to speak to healthcare professionals if they are experiencing prolonged discomfort.