What Is Post Vasectomy Pain Syndrome?

If you have undergone vasectomy, you might be experiencing pain after surgery that most of the time remains temporary and will be resolved within a few days or weeks. However, this can evolve into a long-lasting condition over a few months to a year, named post-vasectomy pain syndrome. The causes and incidence are not yet fully known, but there are some resolutions available that involve non-surgical treatments or surgical treatments when the first approach did not give the expected results. 

What is vasectomy?

Vasectomy is a sterilisation technique for men. It is a surgical procedure performed under local anaesthesia that has as its final goal to stop the sperm going through the vas deferens, tubes in which sperm is carried from the testicles during the ejaculation, so it will not be present in the ejaculated fluid during the sexual intercourse, intended to prevent the fecundation.¹ 

The surgical process is mainly divided into two steps:

1. Isolation of the vas deferens from the surrounding tissue by making an incision in the scrotum to expose the tubes. This can be done with a scalpel through the scrotum or without (non-scalpel vasectomy, or NSV).
2. Occlusion of the vas deferens by blocking them with a hemostat and removal of 1 cm of the vas, to then apply clips or sutures and eventually burn the tip while a hemostat is in place to control the vas deferens ends and facilitate their sealing.²

Vasectomy is considered the most effective long-term contraceptive method for men, demonstrated by the 98% effectiveness rate³, with about 500,000 surgical operations performed in the US yearly.¹ 

Complications and post-vasectomy pain syndrome

If you go under this surgical procedure, some common complications might show up such as bleeding, bruising, and infection on the sites where the scrotum was incised. After surgery, it is also common to experience acute pain locally that resolves usually within 2-4 weeks.

Other complications that can appear later  can include vasectomy failure, the formation of a fistula or chronic pain. Less commonly some patients could experience chronic scrotal pain after the operation that lasts for longer than a simple acute condition, going from a few months to a year. This chronic painful condition following vasectomy is known as Post Vasectomy Pain Syndrome (PVPS) and is therefore identified as chronic pain that can be persistent or discontinuous over a minimum of 3 months or longer. 

In about 1-2% of the patients experiencing PVPS, it would be so painful that it will interfere with their daily activities and affect their quality of life, making them seek medical intervention.³

Overall, if compared to a permanent contraceptive method used in female patients, vasectomy has a higher rate of success and fewer possible post-surgery complications than tubal ligation.⁴

What are the chances of getting pain syndrome after a vasectomy? 

Thankfully, it only affects a very low percentage of patients that undergo vasectomy. The incidence of this condition is not fully known and it has varied from 0.1% to a higher rate of 15% in studies and analysis conducted over the years.⁵ Overall, 33% of men reported some sort of chronic testicular discomfort after the operation. Among these patients, 5% had to ask for medical intervention, and 2% of them resorted to surgical intervention to find resolution and relief.⁴

How do you recognise post-vasectomy pain syndrome?

PVPS can appear usually after 7-24 months after undergoing vasectomy. Some of the signs and symptoms that can help us and the health care professional identify the condition can include:³

• Scrotal chronic pain longer than 3 months
• Sore and sensitive vas deferens 
• Sore epididymis (tube that transports the sperm from the testis to the vas deferens), and possibly related thickening (visible with an ultrasound)
• Full vas deferens
• Testicular pain (orchialgia)
• Pain during ejaculation
• Premature ejaculation
• Painful intercourse (dyspareunia)
• Decreased libido caused by the discomfort experienced

Risk factors in post-vasectomy pain syndrome

It is important to say that factors such as your age, race, socioeconomic status, and the vasectomy technique the surgeon uses do not represent possible risk factors and have not been associated with an increase in being affected by PVPS.^5,3

However, there are two methods to perform a vasectomy as we mentioned at the beginning of the article, which are scalpel vasectomy and non-scalpel vasectomy (NSV), respectively with a scalpel to make the incision in the scrotum and without the scalpel, that sees the surgeon piercing the skin with dissection forceps and by blocking the vas and overlying related skin with an external ring. 

Since the NSV is invasive and therefore traumatic for the patient’s genitals, there is a smaller risk of damaging local blood vessels, nerves and lymphatic system, which tend to be preserved instead. For this reason, the NSV could have a lower risk of causing post-vasectomy pain, therefore also not resulting in chronic pain.⁶ 

What is post-vasectomy pain syndrome caused by?

The causes of this chronic condition are still unknown. However, some common traits that PVPS patients share make us think that it is certainly based on a physical issue and not psychologic.¹ Some of the possible causes are:

• Direct damage of the spermatic structures during the surgical procedure
• Nerve damage and compression due to inflammation
• Fibrosis formed around nerves
• Epididymal congestion of fluid and sperm that creates a blockage 
• Sperm granulomas
• Immunological response

Regarding the immunological response, it has been shown that 60-80% of patients who underwent vasectomy had significantly increased levels of antisperm antibodies in animals during laboratory studies, which therefore can induce an immune response with related inflammatory cascade and correlated pain.¹

Despite these all being possible logical causes, unfortunately, none of them has been demonstrated to be an actual correlation to the chronic pain caused by vasectomy in some patients, and therefore the origin of the condition remains uncertain.⁴

How do you know if you have PVPS?

In order to diagnose post-vasectomy pain syndrome, the doctors will need to perform a double evaluation of the involved patient:

1. History
2. Physical examination

By history we mean analysing and evaluating characteristics of the condition that the patient is experiencing:

• Nature of pain
• Duration of pain
• Severity of pain on a scale from 0 to 10
• Location of the painful area
• Factors that worsen the condition
• Previous therapeutic actions taken to solve the problem
• Other correlated symptoms

It is important to also have a physical evaluation of the genitals. 

During the examination, the patient is evaluated in two positions (standing and supine). 

• Testicles, epididymides, and vas deferens are analysed, but also prostate and pelvic floor are examined to see if there are any abnormalities.
• Laboratory exams: urine culture, semen culture, and urinalysis to rule out that there is an ongoing infection
• Scan of abdomen and pelvis: to rule out the presence of stones in the urinary tract that could cause pain
• Scrotal ultrasound: to evaluate its content and ensure pain is not linked to the presence of testicular tumour, varicocele, or infection 
• MRI scan of spine and hips: to exclude nerve impingement as a cause of the pain experienced
• Spermatic cord block: an injection of anaesthetic (bupivacaine/ropivacaine) to provide temporary relief from chronic pain in the testicles.⁷ This is a helpful technique in case the pain is irradiating from the scrotum content.³

The symptoms experienced with PVPS can also be linked to conditions such as varicocele, tumour, infection, hernia, pelvic floor, or prostate disorders. For this reason, all the above-mentioned exams are necessary to rule out other conditions, as the diagnosis of PVPS can solely be made after excluding them all.³

How do you treat PVPS?

Non-surgical treatment

After vasectomy, it is common and normal to experience some pain. There are several precautions to follow to reduce the duration of pain and heal in a shorter time, which can also prevent the development into chronic pain and therefore PVPS:²

• Use ice locally to reduce possible inflammation 
• Take painkillers such as paracetamol or ibuprofen 
• Limit intensity of physical and sexual activity for 3-5 days after vasectomy
• Avoid bathing or swimming during the first week, while showering is fine to resume
• Use of prescribed antibiotics in case of epididymitis³
• Pelvic floor therapy for people with related dysfunction
• Local anaesthesia for testicles and epididymis (spermatic cord block) and >90% of patients³ has temporary pain relief of variable duration

Surgical treatment

When the non-surgical approach does not work, surgical interventions should be taken into consideration. Some of the methods are:

• Extirpation of sperm granuloma formed 
• Removal of the epididymis 
• Removal of the testicles 
• Microdenervation
• Vasectomy reversal

Microdenervation 

Microdenervation of the spermatic cord (MDSC) is a popular and relatively new type of surgical method that involves cutting all nerves of the spermatic cord, whilst maintaining intact arteries and part of the lymphatic system. 

During a study conducted on 17 patients that had microdenervation, 13 of them confirmed complete resolution of previous chronic pain, whilst the remaining 4 patients still had some significant improvement.³ Several studies showed a good success rate in the use of MDSC when treating post-vasectomy pain syndrome. 

A correlation has been seen between the spermatic cord block and MDSC, demonstrated by the fact that a positive reaction to the spermatic cord block predicts a positive outcome if the patient undergoes microdenervation.³

Vasectomy reversal

Vasectomy reversal is another surgical intervention available that shows a high rate of success. It consists in reversing the vasectomy patients have gone under by connecting the vas deferens previously cut during the sterilisation, and becoming fertile again. 

A study conducted on 32 patients resulted in 84% of them having chronic pain caused by previous vasectomy resolved, with some of them requiring a double vasectomy reversal to have the complete resolution.⁴ In a different study conducted on 31 patients, 82% of them showed improvement.⁴ Moreover, another study on a group of 14 men had 93% of them with improvement and 50% complete resolution of the chronic pain experienced.⁴ Despite this approach being an overall good option, there are still some patients who continue to experience pain in the long term.

Impact on quality of life

The chronic pain caused by the post-vasectomy pain syndrome can inevitably have a significant impact on patients’ quality of life given the constant discomfort they experience throughout the days. 

However, not only does it limits physical activities, but also seems to have important repercussions on their mental health, with consequent psychiatric disorders such as non-genital chronic syndrome, physical somatisation of their emotions, and depression. Most of these men would tend to isolate themselves from others and experience emotional loss, consequently also affecting their relationships. This shows how not only this syndrome is a physical disorder but also psychological, and that therefore requires careful attention.⁴

Summary

Vasectomy is a permanent but reversible contraceptive method for men. It consists of cutting the vas deferens, in which the sperm is carried during the ejaculation. 

After the surgery it can be normal to experience temporary acute pain for a few days or weeks, however, in some cases, it can become chronic and lasts for several months and up to a year, and this is when it is recognised as post-vasectomy pain syndrome. In some cases, the problem can be resolved with some non-surgical treatments such as antiinflammatory medication, painkillers, or application of ice locally.

However, when these solutions do not bring the expected outcome, a surgical intervention will be considered. Microdenervation and vasectomy reversal are currently popular options with a relatively high success rate, giving hope in a possible permanent resolution, even though in some cases the chronic pain cannot be resolved. Speaking with surgeons and doctors will be the best practice to find a solution that can improve your quality of life. 

Given the sensible topic, it is also important to consider not only the physical aspect but also the psychological influence that this can have on the patient. For this reason, seeking emotional help from a professional and people in their lives can represent vital support to deal with the condition.