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:

What Causes the Pain?

The etiology of PVP has yet to be fully elucidated. Because there is no formal definition and the presentation is variable there have been many hypotheses to explain the symptoms. The currently available evidence suggests several processes that lead to the histological findings seen in pathologic specimens removed to treat severe or persistent PVP. There may be a final common pathway leading to chronic testicular or epididymal pain that involves damage to scrotal nervous structures via immune system inflammatory effects, back pressure affects in the post-vasectomy closed system, or via perineural fibrosis from either of these processes. Postulated etiologies for PVP have included pressure from epididymal congestion, inflammation, or compression of paravasal nerves by sperm granuloma (Christiansen and Sandlow, 2003), interstitial fibrosis in the epididymides, or perineural fibrosis (Chen and Ball, 1991).

Studies of epididymectomy specimens from patients with post-vasectomy pain have shown evidence of pathological changes possibly related to longstanding obstruction. This interstitial fibrosis and perineural fibrosis seen in the epididymides of affected men could explain the pain. (Chen and Ball, 1991) Nariculam et al also reported this finding of obstructive changes in all of the epididymectomy specimens in their study of chronic testicular pain. They noted epididymal fibrosis, tubule distension, and focal fibrosis as well as signs of testicular tubular sclerosis and inflammation (Nariculam et al, 2007). Some of the specimens in the Nariculam study showed evidence of testicular infarction suggesting intermittent torsion and the study was not PVP specific.

The epididymides are frequently enlarged or tender on physical examination of PVP patients. Ultrasound or physical examination of scrotal contents of men with PVP shows evidence of sperm granulomas in some, but not all patients. The role of sperm granulomas in the pathophysiology of PVP is controversial. Some postulate a protective role for sperm granuloma at the testicular end of the vas as a “pressure valve” which could help prevent back-pressure related damage. (Shapiro and Silber, 1979) Other studies focus on pain caused by sperm granulomas that require excision. (Schmidt, 1979) In addition, the sperm granuloma is the immune system lesion where sperm are broken down and presented to the immune system resulting in auto-immune antibody formation that may drive some of the inflammation related damage that could contribute to PVP in some patients. Some studies suggest an increase in antisperm antibodies in men with granulomas (Alexander and Schmidt, 1977). This duality of forming a pressure sink for sperm disposal and inflammatory role as a site of auto-immune antibody stimulation leads to residual controversy as to the role of sperm granuloma in PVP. Whether a sperm granuloma is preventative or potentially causative may depend on the size, location, and proximity to nervous structures or amount of associated paravasal inflammation. Removal of sperm granuloma has led to resolution of symptoms is some patients with persistent pain.

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.

Pain After Vasectomy

I started this blog to help men find information about persistent pain after vasectomy. There are about 500,000 vasectomies performed per year in the U.S. According to published post-vasectomy surveys, about 10 to 15% of men develop persistent pain in the scrotum, epididymides (mushy sperm maturation organs attached to each testis), or in the testes after vasectomy. This complication can take years to develop and affects quality of life or sexual function in 2 to 5% of men. Unfortunately, it is not featured on the usual vasectomy consent process and if it is mentioned, it is listed as much more rare ("1 in a 1000"). No mention is made of the inevitable affects of chronic genital pain on the life of the affected men. This blog will focus on this complication and adequate informed consent regarding this tragic outcome of vasectomy.

Despite the common view that vasectomy is completely safe and has no long-term side effects, several post-vasectomy surveys have confirmed that some men have persistent pain after vasectomy. These contemporary studies are published in peer reviewed medical journals and document this problem in a significant percentage of vasectomized men. While most men have trivial short-term pain, some men have pain that lasts a few months, and up to 15% of men still complain of testicular or other scrotal pain seven months after their vasectomy (Leslie et al 2007). After one year, the incidence may decrease, but this has not been proven, and a study of two groups of men one year post-vasectomy and ten years post-vasectomy showed no difference in incidence. (Manikandan et al.)

There are six post-vasectomy survey studies that document the incidence of persistent pain. Severe pain, affects on sexual function, or quality of life are reported in 2 to 6% of vasectomized men in these studies. Summaries are available below and you can access the abstract by clicking the direct links:

1) McMahon et al - 253 surveys sent, 172 responded, and 33% complained of chronic testicular pain. The time interval from vasectomy averaged 4 years and 5% of the men complained of pain during sex. One in sixty respondents regretted having the vasectomy due to chronic pain.

Choe/Kirkemo - 470 surveys sent, 182 responded, and 19% complained of pain. The time interval from vasectomy averaged 5 years and 2% of the men complained of pain that affected quality of life. Nine percent of the men were dissatisfied with their vasectomy.

Morris et al - 198 surveys sent, 101 responded, and 52% complained of some level of pain. The time interval from vasectomy averaged 3 to 4 years and 6% of men complained of pain severe enough to seek treatment.

Ahmed et al - 560 surveys sent, 396 responded, and 5% of men had pain that lasted longer than three months. For some of these men, the pain was severe enough to offer microsurgical denervation of the spermatic cord to treat the pain.

5) Manikandan et al - Surveyed two groups, A. Ten years after vasectomy and B. One year after vasectomy. In group A 460 surveys were sent, 182 responded and 14% had chronic pain. Four percent of the men rated their pain as greater than five on a scale of one to ten (VAS>5). In g
roup 460 surveys were sent, 220 responded and 16% of men complained of pain. Six percent of these men rated the pain as greater than five on a scale of ten.

Leslie et al - 625 patients were approached, and 593 completed the preop survey, while 488 completed a postop survey seven months later and 15% of men reported chronic pain. Four percent of these men reported pain with sex and fourteen percent rated their pain as greater than five on a scale of ten (VAS>5).

Some methodologic flaws could have affected these results which may also be subject to self-selection bias and response bias, however, the numbers are still concerning. If one assumes that ALL of the men who did not return the surveys had NO pain, the pooled incidence of persistent pain from the studies cited above would still be 289/3026 or about 10%.

Most of these authors suggested that chronic pain after vasectomy be included in the vasectomy consent process. This recommendation has not been universally adopted. Chronic pain is the most common post-vasectomy outcome that can affect quality of life.