Post-vasectomy pain syndrome

Vasectomy is a minor procedure that blocks the supply of sperm to the semen. It is a common form of male birth control that is done by cutting and sealing the tubes that carry sperm. The sperm, which can no longer reach the semen, are absorbed by the body.

Vasectomy has a low risk of problems, but some men develop post-vasectomy pain syndrome (PVPS). PVPS involves chronic pain in one or both testicles that is still present three months after the procedure. Pain can range from a rare, dull ache to sharp, constant pain that can interfere with daily life. For some men, the pain is severe enough to seek treatment.

Having some discomfort after vasectomy is common, but men with PVPS have pain that never seems to get better after the procedure.

Signs and symptoms of PVPS may include:

• Pain and tenderness in the scrotum
• Pressure or pain after ejaculation
• Dull ache in one or both testicles
• Pain and tenderness at the site of the vasectomy
• Swelling of the small, C-shaped tube behind the testicle where sperm are stored (epididymis)
• Pain with sex

When to see a doctor

See your health care provider immediately if you have pain or swelling in your testicles, discharge from your penis, or pain when you urinate. Your provider may be able to treat the cause with medicine or a minor procedure.

If you have severe scrotal pain, seek emergency treatment.

The causes of PVPS are not well understood. They may include:

• Infection. Inflammation can damage the scrotum, epididymis or other structures along the cord that carries blood vessels and nerves to the testicle (spermatic cord).
• Nerve compression. A narrowing of nerves to the testicle may cause symptoms of PVPS.
• Back pressure. Sperm that are unable to travel through the tube that carries sperm from each testicle and is cut during vasectomy (vas deferens) may cause back pressure.
• Scar tissue. Scar tissue (adhesions) may form and cause pain.

There are no known risk factors for developing PVPS. It is not associated with any specific age group, socioeconomic status, environmental factors or type of vasectomy procedure.

If left untreated, severe pain may cause significant emotional and psychological distress for men with PVPS. Ongoing pain can affect quality of life for men with PVPS.

Men may be unable to participate in normal physical activity and have trouble working at their jobs. Pain may also result in men avoiding sex.

Your provider will conduct a thorough physical exam, checking for tenderness and swelling of the testicles and epididymis. Your provider will also look for the presence of a small ball of scar tissue where your vasectomy was performed (sperm granuloma).

Other possible causes of testicle pain will need to be ruled out. Tests your provider might recommend include:

• Sexually transmitted infections (STI) screening. A narrow swab is inserted into the end of your penis to obtain a sample of discharge from your urethra. The sample is checked in the lab for STIs such as gonorrhea and chlamydia.
• Urine and blood tests. Samples of your urine and blood are analyzed for infection and any other unusual findings.
• Ultrasound. This is an imaging method that uses high-frequency sound waves to produce images of structures inside your body. Ultrasound might be used to rule out a rotation of a testicle, which twists the spermatic cord that brings blood to the scrotum (testicular torsion); a cyst that develops in the epididymis (spermatocele); infections of the testicle or epididymis; or a hernia.
• Magnetic resonance imaging (MRI). An MRI scan uses a powerful magnet and radio waves to produce detailed images of structures inside your body. MRI may be used to evaluate the spine or hips in men with a history of back or hip problems to rule out nerve compression.

Treatment for PVPS depends on your symptoms and how much pain you have.

Medications

• Pain medications. Anti-inflammatory medications such as ibuprofen (Advil, Motrin IB, others) may help with pain or swelling. Men who have pain before or after ejaculation can take these medications prior to intercourse. Prescription pain medications also may be used to treat pain.
• Other medications. If anti-inflammatory medications do not help after four weeks, your provider may consider a tricyclic antidepressant or an anticonvulsant. These drugs can be helpful in treating nerve pain, although they have not been studied extensively in men with PVPS.

Therapies

• Supportive underwear. Wearing a jock strap or compression shorts may help reduce pain in the testicles.
• Ice or heat. An ice pack or a warming pad may help reduce pain. Sitting in a warm bath also may be helpful during a flare-up.
• Physical therapy. Men who have pain in the pelvic area or when they urinate may benefit from pelvic floor physical therapy to learn how to relax certain muscles in the pelvis.
• Nerve block. Your provider may suggest a nerve block, which uses numbing medication to target the nerve that goes to the testicle. This will probably only temporarily relieve your discomfort. Pain often returns once the numbing medication wears off.

Surgery

• Removal of sperm granuloma. Some men develop a small ball of scar tissue on the vas deferens without pain in any other part of the scrotum. Those men may experience pain relief after a procedure to remove the scar tissue.
• Microdenervation of the spermatic cord (MDSC). In this procedure, the surgeon separates nerves and veins that go to the testicle from other parts of the spermatic cord to reduce or eliminate pain signals. MDSC appears to be most effective in men who experience temporary relief from a cord block. When successful, MDSC can significantly improve quality of life. Complications may include ongoing or worsening pain, development of fluid buildup in the sheath around a testicle that causes swelling in the scrotum (hydrocele), and testicular atrophy.
• Epididymectomy. For men with pain of the epididymis, removing the C-shaped structure that stores sperm behind the testicle may relieve the pain. The procedure seems to be most effective in relieving pain in men who have a cyst, a granuloma or a mass on the epididymis.
• Vasectomy reversal (vasovasostomy). Reversing the vasectomy will restore sperm to the ejaculate and may restore fertility. This procedure may relieve pain and pressure that occur with ejaculation. For some men, vasectomy reversal is more effective than the MDSC approach in relieving pain.
• Orchiectomy. Removal of the testicle is a last resort for men who do not respond to more-conservative treatments. Even after the testicle is removed, men sometimes feel a phantom limb pain in the area where the testicle used to be.

There is not much known about alternative medicine for the treatment of PVPS.

Your provider may consider acupuncture either alone or together with medication. Although there are no clinical trials that prove the effectiveness of acupuncture in treating PVPS, acupuncture is considered safe and noninvasive for men recently diagnosed with PVPS.

What you can do

When you make the appointment, ask if there's anything you need to do in advance, such as fasting before having a specific test. Make a list of:

• Your symptoms, including any that seem unrelated to the reason for your appointment
• Key personal information, including major stresses, recent life changes and family medical history
• All medications, vitamins or other supplements you take, including the doses
• Questions to ask your provider

Take a family member or friend along, if possible, to help you remember the information you're given.

For PVPS, some basic questions to ask include:

• What's likely causing my symptoms?
• Other than the most likely cause, what are other possible causes for my symptoms?
• What tests do I need?
• Is my condition likely temporary or chronic?
• What's the best course of action?
• What are the alternatives to the primary approach you're suggesting?
• I have other health conditions. How can I best manage them together?
• Are there restrictions I need to follow?
• Should I see a specialist?
• Are there brochures or other printed material I can have? What websites do you recommend?

Don't hesitate to ask other questions.

What to expect from your doctor

Your provider is likely to ask you several questions, such as:

• When did your symptoms begin?
• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?

What you can do in the meantime

Avoid doing anything that seems to worsen your signs and symptoms.