Vasectomy is the most popular form of male contraception known for its effectiveness; this simple surgery is minimally invasive and has high success rates in preventing pregnancy. It involves cutting the vas deferens, the two tubes that carry sperm from the testicles to the urethra, to prevent sperm release from the body during ejaculation.¹ Therefore, although sperm is still produced, it dies and is absorbed by the body rather than being released by the penis.¹ However, despite the high success rate,  some men can experience an ongoing pain that can last for a very long time after the procedure; this condition is called post-vasectomy pain syndrome (PVPS). 

PVPS can cause continuous discomfort and pain, affecting their quality of life, mental health, and family relationships. 

While most men with PVPS undergo non-surgical treatments, such as medication, the usage of supportive underwear, nerve blocks, physical therapy, and the use of ice or warming pads, there are times when surgical methods are sought because non-surgical treatments have not worked. 

This article will explain when surgery becomes necessary for PVPS and what surgical options are available. 

What is post-vasectomy pain syndrome?

PVPS occurs when a man has an ongoing. Chronic pain in his scrotum after a vasectomy. PVPS can develop directly after your vasectomy or a few months later and can present as a sharp pain, which can fluctuate in severity or remain constant.

Some potential causes of PVPS include:

• Nerve compression occurs when the nerves within the testicle are narrowed or compressed, leading to pain and potential nerve damage² 
• Inflammation damages the structures, such as blood vessels, that supply the testicles.² Additionally, inflammation can occur when granulomas (small lumps) form because sperm leaks out of the cut tubes, resulting in the body seeing the sperm as foreign objects and, therefore, causing inflammation³
• Scar tissue is created as the body heals²
• Backup pressure caused by the inability of the sperm to flow out due to a vasectomy, resulting in a pressure buildup that can cause pain and swelling²
• Congestive epididymitis occurs when the coiled tube that stores sperm (epididymis) becomes swollen and tender because sperm and fluid cannot drain properly³

These causes can result in pain of different types and intensities. Some people experience constant aches, whilst others have sharp stabbing pains that can come and go. The pain is often associated with worsening during activities, sitting for long periods, and sex. PVPS can impact people’s relationships because it can occur during ejaculation.

However, before doctors consider surgery, non-surgical treatments are administered  first^:2,3

• Waiting: Sometimes the pain goes away on its own over time
• Pain medications: pain and swelling could be reduced by common anti-inflammatory drugs
• Physical therapy: pelvic floor exercises, such as Kegels, can help relax the tight muscles that support the reproductive organs, thus reducing the pain
• Antidepressants: to treat mental health conditions that have developed from PVPS
• Nerve block: temporary reduction in pain by numbing medication
• Supportive underwear: Compression shorts can help hold the testicles and penis to provide support and, therefore, alleviate discomfort
• Heat or ice packs: cold or warmth are commonly known to help reduce pain

When is surgery required?

Surgery is considered when non-surgical treatments have been unsuccessful in reducing symptoms after a few months. The decision on whether surgical methods are the right treatment for you is considered after several considerations:

• How bad is the pain? When the pain is severe and stops you from living a good quality of life and prevents you from your normal daily activities, such as exercising, sleeping, and working, then surgery could be considered sooner
• How long has the pain lasted? If the pain persists for a long time, despite non-surgical treatment, it is more likely to require surgery
• How does it affect your daily life? If the pain interferes with your daily lifestyle and relationships, causes depression or anxiety, then surgery could be considered
• What treatments have you already tried? Non-surgical treatment options are administered before deciding on surgery

Before surgery, doctors conduct thorough testing to identify exactly what's causing the pain and whether surgery would be the best treatment. Testing can include:

• Pain mapping is used to examine where the pain is located and what it feels like
• Ultrasound (Doppler colour flow) to rule out cysts within the epididymis, testicular torsion, infections, and hernia¹
• Blocking specific nerves using numbing medications to identify which nerves are causing the pain
• Routine urinalysis
• MRI to rule out nerve compression⁴
• Sexually transmitted infection (STI) screening
• Ruling out other causes

The different types of surgery for post-vasectomy pain syndrome

There are several options when surgery is required to treat PVPS. The options depend on the cause of the pain and the patient’s specific situation.

Microsurgical spermatic cord denervation (MSCD)⁵

MSCD is the most common type of surgery for PVPSS. MSCD involves cutting the nerves that carry pain signals from the affected area, whilst leaving the important blood vessels and nerves alone. MSCD is particularly useful for people who benefit from nerve block as a non-surgical treatment. However, as with every surgery, there are risks. MSCD can result in infections, bleeding, swelling of the scrotum, and the potential for pain to worsen or some level of pain to remain after surgery.¹

Epididymectomy⁶

Epididymectomy involves the removal of the epididymis when it is identified as the cause of pain. Vasectomy reversal

Vasectomies can be reversed, and the tubes that were cut can be reconnected, which can relieve the pressure buildup that could have been causing pain. However, vasectomy reversals are complex surgeries, and there is no guarantee that they will work for pain relief. 

It is worth noting that there is no significant difference in pain reduction between epididymectomy and vasectomy reversal, indicating a similar level of effectiveness. Therefore, personal considerations such as preference and location of pain are crucial in deciding the treatment option.⁷

Orchiectomy (testicular removal)

The last surgical option could be the removal of the testicles. Orchiectomy is completed when all the other treatment options are unsuccessful or inappropriate. Although the success rate is very high, it is important to consider that this procedure is permanent and irreversible. Additionally, phantom limb pain can develop, which involves the perception of pain within a limb/structure that is no longer present and can cause further emotional distress.¹

Choosing the most appropriate surgery for you

Picking the most effective surgery for each person is crucial and requires careful planning. Therefore, doctors consider many factors:

• Type of pain: people with nerve-related pain often do better with MSCD, whilst those with pressure-type pain could experience better symptoms from vasectomy reversal
• Nerve block results: how a person responds to nerve blocks could determine which type of surgery would work best.
• Personal factors: age, overall health, and personal preferences
• Expectations: it is important that people understand that surgery might not get rid of all the pain, and if one type of surgical procedure does not work, they could need more than one surgical procedure

Therefore, the best approach involves the doctor and the patient working together to decide on the steps that are required.

Conclusion

Post-vasectomy pain syndrome (PVPS) is a serious condition that can greatly impact a person’s life and mental health. Although the incidence rate is low, for people who do get vasectomies, PVPS is an important condition to be aware of, and those who develop it require specialised care.

There are non-surgical treatments that are often opted for initially. However, when these treatments do not work, surgery can often help provide significant relief. The key surgical options include: 

• MSCD 
• Epididymectomy
• Vasectomy reversal
• Orchiectomy

Success rates are generally very good, especially when the right treatment and type of surgery are chosen for the patient. 

The most important things to remember are:

• Surgery should only be considered after trying non-surgical treatments
• Careful testing is required to choose the best type of surgery
• As not all the pain might be alleviated, realistic expectations are required