Christopher L. Starks, MD
Edmund S. Sabanegh, Jr, MD
BASICS
DESCRIPTION
• Vasectomy is a surgical procedure that creates a disruption of the vas deferens leading to permanent male sterilization
– Vasectomy is the safest, least expensive, and most reliable form of sterilization (1,2)
• Postvasectomy pain syndrome: Poorly understood and largely unpredictable chronic testicular pain >3 mo duration after vasectomy
– Variable constellation of symptoms including but not limited to orchalgia, pain with daily activities, and pain with intercourse/ejaculation
EPIDEMIOLOGY
Incidence
• Vasectomy
– Number of vasectomies performed each year is ∼175,000–500,000
• Postvasectomy pain syndrome
– 15–33% of men may experience persistent mild or troublesome testicular discomfort following vasectomy with 4% experiencing significant long-term testicular pain (orchalgia)
– Long-term pain requiring some kind of intervention or surgical therapy occurs in up to 1 in 1,000 vasectomized men
Prevalence
∼5% of couples of reproductive ages rely on vasectomy for contraception
RISK FACTORS
N/A
Genetics
N/A
PATHOPHYSIOLOGY
• Vasectomy
– Vasectomy involves disrupting the vas deferens via suture ligation, electrocautery, clips, and/or fascial interposition
– Vasectomy disrupts the blood–testis barrier
Antisperm antibodies in 60–80% of men
Does not appear to result in cell-mediated immunity
• Postvasectomy pain syndrome
– Proposed mechanisms:
Increased pressure on the testicle and epididymis
High pressure may cause blowouts of sperm resulting in tender sperm granulomas and epididymal regions
Nerve entrapment
Fibrosis
ASSOCIATED CONDITIONS
N/A
GENERAL PREVENTION
No preoperative factors have been identified in the postvasectomy pain syndrome
DIAGNOSIS
HISTORY
• Vasectomy
– A careful history ensuring that the patient understands that this is a permanent method of sterilization should occur
– A directed history including previous scrotal and inguinal surgery
• Postvasectomy pain syndrome
– Mean time to onset of pain reported as 2 yr
– Symptoms associated with postvasectomy pain syndrome include:
Persistent pain in the groin, testicle, or epididymis
Pain with an erection and/or engaging in sexual activity
Pain with ejaculation
Decreased libido and/or erections
PHYSICAL EXAM
• Prevasectomy
– Ideally a preprocedure consultation should occur in person
– Detailed physical exam performed to ensure the vas deferens are easily palpable
– Patients with unusual scrotal sensitivity or anatomy may be identified, and may be recommended for procedure with sedation
• Postvasectomy pain syndrome
– Physical exam commonly reveals fullness/tenderness at the proximal vas, epididymis, or at a granuloma site
– Evidence of sperm granuloma
– Epididymal tenderness or other masses
– Examine for evidence for groin hernia
DIAGNOSTIC TESTS & INTERPRETATION
Lab
N/A
Imaging
• Postvasectomy pain syndrome
– Usually not necessary
– Ultrasound imaging can confirm epididymal engorgement, thickening, or nodularity
Diagnostic Procedures/Surgery
N/A
Pathologic Findings
• Vasectomy
– Routine histologic exam of excised vas segment is not required
– Analysis of testicular histology after vasectomy demonstrates dilatation of the seminiferous tubules, interstitial fibrosis, and reductions in the seminiferous cell population
DIFFERENTIAL DIAGNOSIS
• Postvasectomy pain syndrome
– Hydrocele
– Infection (eg, epididymitis)
– Inguinal hernia
– Intermittent testicular torsion
– Nerve injury or entrapment
– Psychogenic causes
– Referred pain
– Testicular or paratesticular neoplasm
– Varicocele
TREATMENT
ALERT
Patients must be fully informed that an alternative form of birth control must be used immediately after vasectomy and until a semen analysis is clear.
GENERAL MEASURES
• Vasectomy
– A minimally invasive or “no-scalpel vasectomy” technique should be used
– Methods of performing vasectomy are based upon surgeon preference. These include:
Excision of a portion of the vas
Clips vs. suture ligation of vas ends
Cautery of mucosa
Interposition of the vas ends between fascia (may reduce recanalization)
• Postvasectomy pain syndrome
– Conservative therapies are the mainstay: Scrotal support, activity limitation, sitz baths, ice-packs
MEDICATION
First Line
• Postvasectomy pain syndrome
– Antibiotics
Empirically often used with no documented benefit in the absence of obvious infection
– Nonsteroidal anti-inflammatory medication
Prolonged course (>3 mo) suggested before employing more aggressive approaches (see below)
Second Line
Tricyclic antidepressants and neuroleptic medication (eg, gabapentin) can be considered
SURGERY/OTHER PROCEDURES
• Postvasectomy pain syndrome
– With the failure of long-term conservative management, more invasive treatments: Sperm granuloma excision, denervation of the cord, open-ended vasectomy, epididymectomy, and orchiectomy may be considered
– With pain localized to a sperm granuloma on physical exam, granuloma excision with occlusion of vas with intraluminal cautery usually relieves the pain and reduces the risk of recurrence
In 1 study up to 50% were pain free following epididymectomy
Epididymectomy renders the vasectomy completely irreversible and may jeopardize the blood supply to the testes, which can result in ischemic atrophy
Vasectomy reversal: There are no controlled trials, but reversal may offer best chances of significant improvement (50% pain free in 1 series). The drawback is that fertility is restored (3)
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Postvasectomy pain syndrome
– Men with intractable symptoms might benefit from a multidisciplinary team approach involving a urologist and a pain-clinic specialist, including a psychologist
– Many men with chronic orchalgia also had signs of major depression or chemical dependencies (4)
– Spermatic cord blocks
– Local intralesional steroids
– Transrectal injections into the region of pelvic plexus (5 mL bupivacaine and methyl prednisolone) have been used to manage cases of chronic orchalgia and may be considered as salvage therapy in refractory cases (5)
– Neuromodulation and the use of testosterone have also been reported in this setting (6)
Complementary & Alternative Therapies
• Vasectomy
– Patients should continue other means of contraception if they do not desire permanent sterilization
ONGOING CARE
PROGNOSIS
• Vasectomy
– Patients are instructed that vasectomy does not work immediately
– They should use contraception and consider themselves fertile until a postvasectomy semen analysis (PVSA) is negative
– Even once vas occlusion is confirmed, the risk of preventing pregnancy is not 100% reliable. Risk of pregnancy is 1 in 2,000 for men who have PVSA showing azoospermia or rare nonmotile sperm
– Repeat vasectomy is needed in <1%
• Despite counseling, up to 5% of men will change their mind postvasectomy and request a vasectomy reversal
COMPLICATIONS
• Bleeding/hematoma: ∼1–2%
• Infection: <1%
• Symptomatic sperm granuloma: <1%
• Postvasectomy pain syndrome: 15–33%
FOLLOW-UP
Patient Monitoring
• PVSA should be a fresh uncentrifuged semen sample and should be examined within 1–2 hr of ejaculation
• PVSA can be made by the patient between 8–16 wk after vasectomy
• Acceptable PVSA show azoospermia or only rare nonmotile sperm
• Vasectomy should be considered a failure if motile sperms are present at 6 mo
Patient Resources
Urology Care Foundation: Vasectomy http://www.urologyhealth.org/urology/index.cfm?article=53&display=1
REFERENCES
1. Sharlip ID, Belker AM, Honig S, et al. Vasectomy: AUA guidelines. J Urol. 2012;188:2482–2491.
2. Dohle G, Diemer T, Kopa Z, et al. European Association of Urology guidelines on vasectomy. Eur Urol. 2012;61:159–163.
3. Horovitz D, Tjong V, Domes T, et al. Vasectomy reversal provides long-term pain relief for men with the post vasectomy pain syndrome. J Urol. 2012;187:613–617.
4. Granitsiotis P, Kirk D. Chronic testicular pain: An overview. Eur Urol. 2004;45:430–436.
5. Yamamoto M, Hibi H, Katsuno S, et al. Management of chronic orchialgia of unknown etiology. Int J Urol. 1995;2:47–49
6. Morley C, Rogers A, Zaslau S. Post-vasectomy pain syndrome: Clinical features and treatment options. Can J Urol. 2012;19(2):6160–6164.
ADDITIONAL READING
Tandon S, Sabanegh E. Chronic pain after asectomy: A diagnostic and treatment dilemma. BJU Int. 2008;102:166–169.
See Also (Topic, Algorithm, Media)
• Sperm Granuloma
• Spermatocele
• Testis, Pain (Orchalgia)
• Vas Deferens, Obstruction
• Vasectomy Reversal
CODES
ICD9
• 338.18 Other acute postoperative pain
• 608.89 Other specified disorders of male genital organs
• V26.52 Vasectomy status
ICD10
• G89.18 Other acute postprocedural pain
• N50.8 Other specified disorders of male genital organs
• Z98.52 Vasectomy status
CLINICAL/SURGICAL PEARLS
• A minimally invasive approach to accessing the vas (ie, no scalpel vasectomy) should be used.
• There are a variety of methods and techniques that can be used to disrupt the vas bilaterally including excision, clips, suture ligation, cautery, and fascial interposition.
• There are rare complications from vasectomy including hematoma and postvasectomy pain syndrome.