Post Vasectomy Pain
Post Vasectomy Pain (PVP)
What is PVP?
• A chronic relapsing testicular ache whose onset may be as little as eight weeks to as long as five years or more post-vasectomy.
• PVP may occur immediately after ejaculation, or the pain may be of insidious onset over subsequent days.
• The pain is chronic, lasting for years with relapses usually lasting 1-4 days though very variable in frequency
• Often, the pain is unilateral or at least more severe on one side than the other.
• PVP should, where possible, be a diagnosis of exclusion after the investigation has failed to identify any other lumbar of urological abnormality.
Differential diagnosis
We advise the exclusion of lumbar spinal problems, prostatic disease, and infection in the epididymis and varicocele.
Spectrum of severity
As with other diseases, there is a spectrum of severity, with symptoms varying from trivial and short-lived to severe and persistent. At its most severe, PVP can affect the patient’s everyday life leading to irritability, depression and relationship problems. GPs, urologists and ultrasound departments will all be familiar with vasectomy patients reporting post-vasectomy discomfort. Most PVP suffers will be reassured by a normal US Scan's exclusion of testicular malignancy, but some will require intervention.
Clinical findings
Examination generally shows a completely normal testis but a swollen, often tender epididymis in which there can be firm swellings and possible concretions due to sperm stasis. On the vas, sperm granuloma may be present but, in our experience, does not cause PVP. Sometimes one testicle can be riding higher than the other during the increased pain severity episodes. This is due to a phenomenon called retraction caused by the contraction of a sleeve of muscle around the bundle called the spermatic cord in which the testicle hangs. Each retractile episode can be a cause of pain too.
Aetiology (causation)
Various suggestions have been made, including nerve irritation by scarring at the site of vasectomy, epididymal distension and formation of sperm granuloma. The investigation has shown no histological correlations post vasectomy changes in the vas, epididymis or testis to the presence of PVP. Therefore PVP is an individual response to the vasectomy. At Best Life Microsurgery we believe that early PVP is mostly caused by pressure buildup in the epididymis leading to distension of this delicate structure and its overlying fascia. Of course, we deal with other causes too. By all means, one must try all non-operative methods of treatment before embarking on any surgical treatment.
Treatment
Various treatments have been devised for PVP. These include excision of the epididymis(Epidydimectomy), converting the vasectomy to open-ended and reversal of vasectomy and, in extreme cases, removal of the testis. In our view, reversal is a good option as this is a simple day-case procedure without risk of significant complication and has a proven high success rate. Reversal of the vasectomy allows the accumulated sperms and fluid to drain freely, thus allowing the epididymis to deflate and return to normal. We also perform the removal of granuloma and division of cremaster if necessary as part of the procedure. One word of caution if the connection scars and closes, the pain is likely to return, so the excellence of technique quality and accuracy of microsurgery is all important.
As with any treatment for any pain, there is no guarantee of relieving the pain, and of course, there are risks associated with any treatments, medical or surgical, including Reversal.
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