Thursday, March 26, 2009

Treatment Options

Once a diagnosis of PVP has been made, there are several treatment options available. Conservative treatment includes use of a scrotal support to decrease movement of affected and inflamed areas, avoidance of sexual activity or vigorous physical activity, heat therapy to support the cellular response to congestion and inflammation, and anti-inflamatory medications such as Motrin, Aleve, or Celebrex (if there are no contraindications). Antibiotics have not been used successfully in the absence of overt infection. Some patients report positive results with ice to the affected area or pool therapy, perhaps due to the cool water and lack of effects of gravity on scrotal contents. In a recent review, Tandon and Sabanegh recommended conservative management and three months of NSAID treatment before moving on to more aggressive treatment options. Some men with mild PVP respond to the conservative approach and their pain does not last longer than three months. A condition called congestive epididymitis frequently follows this time course and may resolve in weeks or months with conservative management. This benign course may be seen in men with a less vigorous anti-sperm antibody response, or in patients where the compensatory mechanisms for sperm absorption and removal are not easily overwhelmed. In a large retrospective case series reported by Ahmed et al, 5% of patients had pain that lasted longer than three months, but the Leslie et al prospective audit noted 15% of men had pain at seven months post-vasectomy. Clearly, there is something different about the patients who continue to have pain and require further medical or surgical treatment. Spontaneous remission of PVP becomes increasingly rare after nine months and these men usually need more definitive treatment, although there are individual reports of patients symptoms "settling down" as late as three years post-vasectomy. Watchful waiting and conservative management might be advocated as long as the symptoms are improving, not disabling, and are not having severe effects on sexual function. There are no studies in the literature on the effect of this waiting and conservative management as to final treatment outcome. A case could be made for more definitive treatment after three months of conservative treatment based on the severity of symptoms, effects on sexual function, and the likelihood of increased chronic neuropathic pain development related to symptom chronicity.

If conservative treatments fail to provide relief, pain management strategies can be utilized while considering more definitive treatment. Nerve blockade in the spermatic cord may be attempted especially in cases where neuralgia is expected based on the patient’s symptoms and physical exam, but relief would seem to be transient and this would not address the underlying inflammatory process. A third of the patients in the Nangia et al series had nerve block procedures and yet their pain persisted and required vasovasostomy (Nangia, et al, 2000). There is a case series of three patients in the literature treated using pulsed radiofrequency of nerves supplying the affected area, but these treatments may have more utility in CTP or groin pain after hernia surgery, than in PVPS (Cohen and Foster, 2003). Using chronic pain approaches with antidepressants or anticonvulsants has produced poor results in general in post-vasectomy pain patients while helping others with idiopathic orchialgia (Sinclair et al, 2007). There is a case report in the literature promoting the use of testosterone cypionate injections of 400mg monthly for three months to suppress sperm production to treat PVPS. The hypothesis that PVPS is due to inflammation and chronic antigenic stimulus from sperm seems plausible, but this treatment has not gained in popularity and prospective confirmation of efficacy is lacking (Pienkos, 2007). The idea that by inducing azoospermia, one could treat the inflammation and delay or prevent perineural scarring and fibrosis in the epididymides is novel and worthy of a randomized controlled trail to possibly add to the non-surgical treatment of PVP as this treatment preserves desired sterility.

Definitive treatment of PVPS that fails conservative management is primarily surgical. A variety of procedures have been tried with varying degrees of success. They are listed here in increasingly aggressive order: Conversion to open vasectomy, microsurgical denervation of the spermatic cord, vasovasostomy, epididymectomy, and inguinal orchiectomy (Granitsiotis and Kirk, 2004). Conversion to open vasectomy is felt to reduce the pressure buildup in the closed system and encourage the formation of a sperm granuloma to relieve this pressure over time. There is a small series in the literature showing resolution of “pain on ejaculation after vasectomy” by this technique (Edwards and Errey, 1982). Microsurgical denervation of the spermatic cord has been used to treat chronic orchialgia of any cause with good results in over 70% of patients in some series (Levine et al, 1996, Strom and Levine, 2008), but was associated with testicular atrophy in a small percentage of cases. One series reported by Heidenreich et al achieved success in 96% of patients and concluded: “Microsurgical testicular denervation results in reliable and reproducible excellent therapeutic success rates of 96% and should be integrated in the management of CTP at an early stage. High success rates require adequate and meticulous diagnostic work-up of the patients by spermatic cord block using saline as placebo and different local anesthetics as an initial therapeutic armentarium predicting postoperative outcome” (Heidenreich et al, 2002). Their results may not directly apply to PVPS patients as these studies involved CTP patients.

Vasovasostomy has been effective in up to 75% to 85% of patients and has been studied specifically with PVPS patients (Myers et al, 1997, Nangia et al, 2000), but restores unwanted fertility. In the Myers et al series, eight patients of thirty-two had continued symptoms and six of these underwent a second reversal procedure, eventually leading to resolution of pain in twenty-seven of thirty-two patients in the series. In another series, vasovasostomy resulted in complete resolution of pain in nine of thirteen patients with PVPS (Nangia et al, 2000). In the Nangia et al series, when they included complete cure or significant improvement as an endpoint, they had success with 85% of patients. Twenty three percent of the patients in the Nangia et al series and nineteen percent of those in the Myers series required a second surgical intervention; generally repeat vasovasostomy, for pain relief. Several patients had relief that lasted months or years, only to have reoccurrence. Despite its success, insurance carriers do frequently not cover vasovasostomy for PVP and cost of the procedure can be a barrier for some patients.

Epididymectomy was effective in 50% of patients in a small series of ten patients with PVP (Chen and Ball, 1991). In another series, fourteen of sixteen patients improved with epididymectomy and factors associated with poor outcome included testicular or groin pain, erectile dysfunction, and normal ultrasound appearance of the epididymides (West et al, 2000). Sweeney at al that concluded that epididymectomy has a limited role in PVP after a poor response rate in their series (Sweeney et al, 2008). As a tragic last resort, inguinal orchiectomy has been used to treat refractory PVP with varying success.

For more information and medical references, refer to my other post-vasectomy site: www.VasectomyPain.org.

1 comment:

  1. Excellently written article, if only all blogger offered the same level of content as you, the internet would be a much better place. Please keep it up!.Great tips, I would like to join your blog anyway.Waiting for some more review.Thank you
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