Introduction

A vasectomy is a form of birth control for males that causes permanent sterilisation. During this procedure, the tubes that pass sperm from the testicles to the penis are either cut, tied or sealed to prevent the possibility of conception during sexual intercourse. Although vasectomies are widely known to be safe and effective, like most surgeries they can also come with side effects and complications such as post-vasectomy pain syndrome (PVPS).^1,2

Vasectomies have been known to have a 99% success rate. However, there can also be early and late failure rates for some patients. The early failure rate of vasectomy involves motile sperm that is present three to six months after a vasectomy, and this can range between 0.3 to 9%. In comparison, the late failure rate of vasectomy is much lower with a range between 0.04% to 0.08%, and this can take place when the detached ends of the vas deferens (sperm duct) join together.³

What is post-vasectomy pain syndrome?

PVPS is an uncommon complication that can take place in one or both testicles and is diagnosed by having continuous or intermittent pain that exceeds three months post-surgery. It has a late onset which can range between seven to twenty-four months.⁴ From a study that analysed a collection of articles on how prevalent PVPS is after a vasectomy found that the incidence of PVPS ranged between 0.4% to 20%.⁵ 

Pathophysiology

The pathophysiology of PVPS is still inconclusive, with theories suggesting that it can be due to the epididymal ducts being blocked or enlarged which can result in tissue scarring. In addition to inflammation which damages the scrotal and spermatic cord nerve structures. Theories also suggest that back pressure between the vas and epididymis due to obstruction can also trigger PVPS. From a microscopic level, patients with PVPS have been shown to have thickened basement membranes and a decline in spermatid cells. Another possible theory suggests that due to vasectomised patients having a change in natural ejaculation, the testicular fluid gets released to the tail of the epididymis which leads to a rise in pressure and consequential scarring. Furthermore, vasectomies damage the blood-testis barrier which releases anti sperm antibodies that can trigger an inflammatory response and potentially cause PVPS.⁶

Figure 1: Diagram of the testicular anatomy (The Testicular Cancer Resource Centre, 2018)

Differential diagnosis

• Infection (such as epididymitis)
• Tumour
• Trauma to the area
• Testicles that have rotated and twisted
• Pelvic floor muscle pain
• Enlargement of the veins within the scrotum
• Fluid buildup that causes swelling in the scrotum
• Inguinal hernia⁶

Management

Pharmacotherapy can be considered first line in managing PVPS. Medicines used include non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, and these can be used adjacent to physical therapy such as pelvic floor exercises and acupuncture. If treatment is unsuccessful, a vasectomy reversal may be required in patients with debilitating pain.⁷

Non-steroidal anti-inflammatory drugs

NSAIDs are drugs that provide pain relief, reduce inflammation and lower fevers. They act by blocking the enzyme cyclooxygenase (COX), which reduces prostaglandin production, and thereby minimises the inflammatory response. There are two subtypes of NSAIDs, which include non-selective NSAIDs that block both COX-1 and COX-2, such as ibuprofen, naproxen and aspirin. And selective NSAIDs that primarily block COX-2 such as celecoxib. 

COX-1 can be found in many tissues of the body. The enzymes play a role in producing prostaglandins that are essential in protecting the lining of the stomach and for platelet activation, as well as maintaining kidney function. In comparison, COX-2 is the enzyme primarily involved in triggering the inflammatory response and pain.

In PVPS, NSAIDs are the first line of treatment, and patients are trialled with a two to four week course, for example with ibuprofen or naproxen. NSAIDs work more effectively in patients who have had PVPS less than a year since having their vasectomy.⁶

Side effects

As non-selective NSAIDs target both COX-1 and COX-2 enzymes, undesired effects of stomach irritation, discomfort and ulceration are more common, compared to selective NSAIDs that mostly target COX-2. Therefore, it is recommended to take these with or after food to reduce these adverse effects. Other side effects of NSAIDs include: 

• Reduce kidney function
• Increase in blood pressure
• Increase in bleeding risk
• Increase risk of heart complications (heart attacks and strokes)⁸

Corticosteroids

Corticosteroid injections (also known as steroids) are also a treatment option for PVPS; however, it is not the first line. Triamcinolone acetonide is used in conjunction with anaesthesia (such as bupivacaine) to perform a spermatic cord block to ease testicular pain. In this treatment, 9mls 0.5% of bupivacaine and 10mg of triamcinolone acetonide are used to conduct a series of four or five spermatic cord blocks with a two to three week interval.⁹

Triamcinolone acetonide works by dampening down the immune system and has anti-inflammatory properties. It works by blocking the phospholipase A₂ enzyme, which disrupts the arachidonic acid pathway shown in Figure 2. As arachidonic acid cannot be generated, it decreases the production of the COX enzymes. This results in a reduction in COX enzyme activity in producing inflammatory markers, and this consequently reduces inflammation.

Side effects

• Increase in blood pressure
• Weight gain
• Osteoporosis
• Increase in blood sugars
• Acne
• Swelling in the ankles and feet¹⁰

Figure 2: The arachidonic acid pathway (van der Heide HJL, Koorevaar RCT,  Lemmens JAM, and van Kampen A, 2007)

Other treatment options

Apart from NSAIDs and corticosteroids, other drug therapies can also be used to treat PVPS. These include a two to four week course of antibiotics such as co-trimoxazole (trimethoprim combined with sulfamethoxazole) or quinolone antibiotics (such as ciprofloxacin) in patients with signs of an infected or inflamed epididymis. These antibiotics are preferred as they can pass through the testes and epididymis well. Another option is tricyclic antidepressants like nortriptyline and amitriptyline, however, they can take up to two to three weeks to show effect.

Anticonvulsants for example gabapentin and pregabalin are also treatment options. Gabapentin 300mg eight hourly with or without amitriptyline 10mg to 20mg daily for a course of three months has been trialled for PVPS patients.

However, although treatment options like tricyclic antidepressants and anticonvulsants have been tried in PVPS patients, there are limited studies to show their efficacy in treating the condition.^6,9

FAQs

How common is PVPS?

PVPS is a rare type of complication that can occur after a vasectomy. Studies have shown that it can happen between 0.4% to 20% of patients.

What can cause PVPS?

The origin of how the disease occurs is still unclear. There are many theories that suggest the disease could have occurred from things like inflammation, back pressure and scarring within the tissues of the testes.

Can PVPS be treated?

Yes, PVPS can be treated. Medicines like NSAIDs are first line such as ibuprofen or naproxen which provides pain relief and reduces inflammation. Patients may also try acupuncture or pelvic floor exercises for additional benefit. If NSAIDs are unsuccessful, other treatment options like tricyclic antidepressants, anticonvulsants that provide pain relief in the nerves, corticosteroid injections or reversal surgery are also available.

What are the differences between NSAIDs and corticosteroids?

Corticosteroids are a type of hormone and are more potent in providing an anti-inflammatory effect compared to NSAIDs which are pain relievers. Corticosteroids have the ability to suppress the immune system to slow down inflammation, whereas NSAIDs do not have an effect on the immune system.

What are the different types of NSAIDs?

There are two different types of NSAIDs that are available, which are non-selective and selective NSAIDs. Non-selective NSAIDs (ibuprofen, naproxen, indometacin and mefenamic acid) bind to both COX-1 and COX-2 enzymes, whereas selective NSAIDs (celecoxib and etoricoxib) mostly bind to COX-2 enzymes. Although selective NSAIDs are more selective on COX-2 enzymes, they can still bind to COX-1 enzymes but less strongly. Other NSAIDs are also available like diclofenac, etodolac, nabumetone and meloxicam, which are non-selective NSAIDs but with a preference for COX-2 enzymes. Because of this, COX-2 selective NSAIDs are generally preferred in patients with stomach issues such as ulcerative colitis, Crohn's disease and active stomach ulcers as they have less risk of irritating the stomach lining.

I think I have PVPS. What should I do?

If you have had a vasectomy and have recurring pain that is more than three months post-surgery, then it is possible you may have PVPS. It is recommended to consult with a healthcare provider as there are other complications other than PVPS that can happen after a vasectomy.

Summary

Post-vasectomy pain syndrome is a rare complication that can occur after a vasectomy procedure. It can be treated with physical therapy such as acupuncture or pelvic floor exercises, or with drug therapy such as NSAIDs and corticosteroid injections. When all options are exhausted, surgical intervention may be required as a last resort, for example, a vasectomy reversal in patients with severe and persistent pain.