Thursday, March 26, 2009

More Info on Pain After Vasectomy

Post-vasectomy pain (PVP) is usually characterized by chronic or intermittent testicular and/or epididymal pain and is frequently worsened by intercourse or ejaculation. PVP can be exacerbated by vigorous physical activity, and is frequently accompanied by tender or full epididymides (Nangia et al, 2000, Myers et al 1997). Symptoms can be unilateral or bilateral and the pain can radiate into the groin or abdomen along the course of the spermatic cord structures. Some patients report a pinching pain near the tail of the epididymides or a burning pain somewhere in the distribution of the genitofemoral nerve.

The diagnosis of PVP is based on a history of vasectomy, symptoms consistent with the diagnosis, a physical exam confirming the presence of associated findings, and the exclusion of other urogenital tract pathology with appropriate laboratory or sonographic studies. The differential diagnoses to be excluded include: neuralgia or neuroma, varicocele, hydrocele, infection, tumor, intermittent testicular torsion, inguinal hernia, and psychogenic causes. (Christiansen and Sandlow, 2003) These entities are fairly easily excluded with appropriate history gathering, physical exam, and routine diagnostic testing. With neuropathic pain, the character and location of the pain may be different and present earlier with localized sharp, burning, intense pain for neuralgia versus a dull testicular aching (with or without intermittent sharp testicular pain) for PVP, allowing diagnosis and treatment to follow the appropriate route. Traumatic neuromas following nervous injury from vasectomy are also sensitive to light pressure. The association of pain with orgasm or after sex in patients with PVP may help differentiate neuroma or neuropathic pain from congestive pain. This distinction is important as neuropathic pain due to nerve injury is not likely to respond to vasovasostomy (vasectomy reversal), while congestive pain patients do well after this treatment.

There are no studies in the literature that explore the specific sexual effects of post-vasectomy pain (pain associated decrease in libido, changes in orgasmic response or ejaculation, decrease in sexual enjoyment, or pain related erectile potency issues). It seems likely that any significant genital pain associated with sex could affect sexual response, potency, or sexual enjoyment, or affect libido and mood. The psychological morbidity of chronic genital pain after vasectomy is not well represented in either the psychiatric or urological literature. There are no studies to support the hypothesis that post-vasectomy pain is a psychosomatic disorder. Treating PVP as a psychological problem is not likely to help the affected patient. As with any type of chronic pain, depression is a possible comorbid condition and may require seperate treatment, but the most effective treatment for comorbid depression is directed at relieving the underlying PVP.

There are several studies that describe the location of and characteristics of chronic genital pain after vasectomy. In a series of thirteen cases discussing vasectomy reversal to treat chronic post-vasectomy pain by Nangia et al, the patients had a variety of genital pain complaints: nine had testicular pain, epididymal pain was present in two, four had pain on ejaculation, and eight had pain during intercourse (Nangia et al, 2000). In a similar series of thirty-two patients, all of the patients complained of unilateral or bilateral testicular pain characterized as a dull ache that increased with sexual arousal, intercourse or ejaculation (Myers et al, 1997). In a retrospective postal study of 172 post-vasectomy patients, 56 (33%) had chronic testicular discomfort and 26 of these considered it to be “troublesome”. In this series, the pain was primarily described as an intermittent and unilateral “dull ache”, but some described a “sharp severe pain”. This sharp pain is usually testicular and can increase in frequency after intercourse. Five percent of the patients surveyed had pain associated with intercourse (McMahon et al, 1992) and the Leslie et al prospective audit reported that 4% of the 488 men had pain with intercourse. Other patients with post-vasectomy pain have required epididymectomy for relief of pain. In a series of ten patients, nine had constant pain in either the testes or epididymides. Four of ten had pain with activity, and three had pain during intercourse (Chen and Ball, 1991).

Chronic neuropathic pain or painful neuroma is also possible after vasectomy due to injury of spermatic cord nervous structures. This type of post-surgical pain has primarily been described with nerve damage after other pelvic or inguinal surgery (Ducic et al, 2006), but has been reported to occur with vasectomy (Murovic et al, 2005). Traumatic neuralgia and neuroma can cause post-vasectomy pain but represent a completely separate entity and require different treatment as was noted in a six case series of this presentation of testicular pain after inguinal herniorrhaphy (Amid, 2006). Patients with traumatic neuralgia typically present earlier than classic PVPS patients (Christiansen and Sandlow, 2003). The neuropathic pain related to injury of a pelvic nerve can cause testicular pain (Ducic I, Dellon AL, 2000) but the presentation, etiology, and treatment options differ for these patients. The lack of pain after sex frequently differentiates this type of PVP from the much more common congestive PVP. There are anecdotal reports of some patients with neuroma or neuropathic pain improving with neurectomy or treatment with anticonvulsant medications such as Lyrica, Neurontin, Tegretol, or Gabatril.

You can see from the medical studies above you are not alone. Persistent pain after vasectomy has been described in the Urological literature since the late 1970's. There are effective treatments for many types of persistent pain after vasectomy. Any pain that lasts longer than three months requires specialist evaluation. Treatment options vary based on the diagnosis that follows a physical exam of the scrotal contents, any needed laboratory studies, and a scrotal ultrasound if indicated. Most of the time, ruling out other possibilities for the pain is a necessary, albeit frustrating process.

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