Trip Answers

Question answered:05/06/08

We found two sources listing complications following vasectomy.

 

GPNotebook states:

 

“There is no evidence that vasectomy results in an increased risk of cardiovascular disease, prostatic or testicular cancer, erectile failure or autoimmune disease. There is no evidence linking osteoporosis development and previous vasectomy.
• early complications following vasectomy occur in 1–6% of men
o early complications include haematoma, wound infection, sperm granuloma, epididymitis–orchitis and congestive (non-infective) epididymitis
? the most common side effects are wound haematoma and staphylococcal wound infection
? most men will develop wound haematoma to a degree, but large problematical haematoma formation is rare. Development of postoperative haematoma may be limited by adequate scrotal support and by the avoidance of physical exercise for up to 3–4 days following the procedure
• late complications following vasectomy
o chronic testicular pain has been found to be the most common late complication and men should be informed of this possibility
o significant chronic orchalgia may occur in up to 15% of men after vasectomy.” [1]

 

In addition, the PatientPlus website lists the following complications:

 

“Other Complications
Mild bleeding into the scrotum: one in 400
Major bleeding into the scrotum: one in 1000
Infection: one in 100
Epididymitis: one in 100
Sperm granuloma: one in 500 - seen as tender scrotal swelling near proximal end of vas and requires further excision
Persistent pain: one in 1,000
Fournier gangrene - a rare form of necrotising fasciitis following vasectomy, requiring emergency treatment with intravenous antibiotics.” [2]

 

Concerning causes and treatments for post-vasectomy pain, ATTRACT (the Welsh primary care clinical Q & A Service) answered a question in 2002. We have searched for studies published this date and have found no new studies cited in the Medline database thus we will reproduce this answer below.

 

Question: Following vasectomy is there a recognised complication of genital pain with no obvious cause, which develops months or even years later?

 

Answer:

 

We found three studies that have evaluated post-vasectomy pain syndrome.

 

The first is a retrospective study carried out in Ohio. The authors suggest the cause of post-vasectomy pain syndrome is unclear, with some possible causes including epididymal congestion, tender sperm granuloma and/or nerve entrapment at the vasectomy site. The study examined 13 men who underwent vasectomy reversal for post-vasectomy pain syndrome. " Mean time to pain onset after vasectomy was 2 years. Presenting symptoms included testicular pain in 9 cases, epididymal pain in 2, pain at ejaculation in 4 and pain during intercourse in 8. Physical examination demonstrated tender epididymides in 6 men, full epididymides in 6, a tender vasectomy site in 4 and a palpable nodule in 4. No patient had testicular tenderness on palpation. Unilateral and bilateral vasovasostomy was performed in 3 and 10 of the 13 patients, respectively. Postoperatively 9 of the 13 men (69%) became completely pain-free. Mean followup was 1.5 years. We observed no differences in vasectomy site histological features in patients with the post-vasectomy pain syndrome and matched controls, and no difference in histological findings in patients with the post-vasectomy pain syndrome who did and did not become pain-free postoperatively. No histological features aid in identifying a cause of pain or provide prognostic value for subsequent pain relief. Vasectomy reversal appeared to be beneficial for relieving pain in the majority of select patients with the post-vasectomy pain syndrome". [3]

 

The second study a retrospective postal survey assessed the role of nerve stripping (denervation) of the spermatic cord in the incidences of chronic postvasectomy testicular pain.

 

" 560 patients (mean age 36 years, range 25-55; mean time since vasectomy 19 months, range 8-39) who underwent vasectomy between July 1992 and December 1994 was carried out to determine the incidence of CPTP. A prospective study was conducted in a further group of 17 patients (mean age 43 years, range 34-60), who had had CPTP for at least one year, to evaluate the effectiveness of nerve stripping of the spermatic cord in relieving pain. RESULTS: Of 396 replies, 108 (27.2%) patients complained of some testicular pain following their vasectomy operation. In 88 (82%) of these 108 patients the pain was brief and was not defined as CPTP, while 20 (19%) patients had pain for > 3 months; 33 (31%) patients required analgesics to control the pain. Of the 17 patients who underwent spermatic cord denervation, 13 reported complete relief of pain at their first follow-up visit and were discharged. Four patients had a significant improvement in the symptom score and were satisfied with the results. There is a small but significant incidence of CPTP and patients should be warned of this possibility when counselled before operation. Denervation of the spermatic cord seems to be a viable surgical option for patients with CPTP who fail to respond to conservative measures". [4]

 

The third study a histological review examined epididymectomy for post-vasectomy pain.

 

"Fifteen epididymectomies were performed on 10 patients with post-vasectomy pain and 12 specimens were available for histopathological review. The findings were compared with those in 2 groups in which epididymectomy was performed for chronic epididymo-orchitis and epididymal cysts. The results showed that 50% of the post-vasectomy group were cured by simple epididymectomy. Pathological findings revealed features of long-standing obstruction and interstitial and perineural fibrosis which may have accounted for the pain. It is important to recognise this late complication of vasectomy and, if surgery is to be performed, to include all of the distal vas and previous vasectomy site in the excision". [5]

 

The RCOG issued a guideline on sterilization in 2004 in which they discuss chronic testicular pain after vasectomy:

 

“Men should be informed about the possibility of chronic testicular pain after vasectomy.
Chronic pain, which can be described as testicular or scrotal and may develop months or years after the vasectomy, is an important complication of a procedure that is done for essentially social rather than medical reasons. The incidence of chronic post-vasectomy pain ranges from 12% to 52%, depending upon the study population. This is likely to represent an overestimate, as most of the studies involved questionnaire surveys, to which men with complications may be more likely to
respond. The proportion of men who sought help or whose quality of life was adversely affected was between 0.9% and 5.2%.

 

The only study that tried to assess testicular pain in a control group of men without vasectomy found a prevalence of pain of any type to be present in 26%.267 However, while vasectomy was associated with a doubling of the rate of occasional testicular pain (47% versus 23%, 95% CI for a difference 10–35%), severe testicular pain was reported in only 6% of cases and 2% of controls. None of the vasectomised men expressed regret.

 

Epididymectomy, vasovasostomy and denervation of the spermatic cord have been described in case series as effective treatments for this condition but no randomised controlled trials were found. Two randomised controlled trials have shown that the injection of a local anaesthetic into the vas at the time of vasectomy may prevent chronic pain; further studies with longer follow up are warranted.” [6]

 

References
1. GPNotebook. Vasectomy – complications. (http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1442447346&linkID=31664&cook=yes)
2. PatientPlus. Vasectomy. July 2007. (http://www.patient.co.uk/showdoc/40024647)
3. Nangia AK, Myles JL, Thomas AJ Jr. Vasectomy reversal for the post-vasectomy pain syndrome: a clinical and histological evaluation. Journal of Urology 2000 164 (4) 1939-42. (http://www.hubmed.org/display.cgi?uids=11061886)
4. Ahmed I, Rasheed S, White C, Shaikh NA. The incidence of post-vasectomy chronic testicular pain and the role of nerve stripping (denervation) of the spermatic cord in its management. British Journal of Urology. 1997 79 (2) 169-70. (http://www.hubmed.org/display.cgi?uids=9052481)
5. Chen TF, Ball RY. Epididymectomy for post-vasectomy pain: histological review. British Journal of Urology 1991 68 (4) 407-13. (http://www.hubmed.org/display.cgi?uids=1933163)
6. RCOG. Male and female sterilization. 2004. (http://www.rcog.org.uk/resources/Public/pdf/sterilisation_full060607.pdf)

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